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THE 



ADVANTAGES AND ACCIDENTS 



OF 



ARTIFICIAL ANiESTllESIA. 



BY . 
LAURENCE TURNBULL, M.D. 



PHILADELPHIA: 
LINDSAY AND BLAKISTON. 

1878. 



THE 



ADVANTAGES AND ACCIDENTS 

OF 

ARTIFICIAL ANESTHESIA. 

BEING 

A MANUAL OF AHJESTHETIC AGENTS, 

AND THEIH 

MODES OF ADMINISTRATION, 

CONSIDERING 

THEIR RELATIVE RISK, TESTS OF PURITY, TREATMENT OF ASPHYXIA, 
SPASM OF THE GLOTTIS, SYNCOPE, ETC. 



v BY 

LAURENCE TURNBULL, M.D.,Ph.G., 

FELLOW OF THE AMERICAN ASSOCIATION FOR THE ADVANCEMENT OF SCIENCI 

FORMERLY LECTURER ON CHEMISTRY APPLIED TO THE ARTS, 

FRANKLIN INSTITUTE; AURAL SURGEON TO JEFFERSON 

COLLEGE HOSPITAL; VICE-PRESIDENT OF THE 

MEDICAL SOCIETY OF THE STATE OF 

PENNSYLVANIA. 

WITH TWENTY-FIVE ILLUSTRATIONS. 






PHILADELPHIA: 
LINDSAY AND BLAKISTON. 

1878. 




7T 



Eutercil according to the Act of Cougress, in the year 1878, by 

LAURENCE TURNBULL, M.D.,Ph.G., 
in the Office of the Librarian of Congress. All rights reserred. 



PHILADELPHIA \ 
COLLINS, PBIHTKR 

70u Jayne Street. 






PREFACE 



This little work was originally written by the Author 
as a Report for a Medical Society, and was subsequently 
extended to its present form to supply a want that evi- 
dently exists at the present da}', for a convenient hand- 
book, on the administration of the various anaesthetics, 
that the practitioner of Medicine or Dentistry can con- 
sult to enable him to decide which one he can best employ. 
Many A r aluable books have, unquestionabty, been written 
on the subject of anaesthetics, but, as far as the writer's 
observation extends, none of a practical character have 
appeared within the last few 3 T ears. Much useful matter 
in relation to sulphuric ether, nitrous oxide, and chloro- 
form, employed as anaesthetics, has accumulated within 
this period, but this valuable information is contained 
in various monographs, journals, etc., where, associated 
with what is extraneous, it is unprofitable to the busy 
practitioner. 

The object of this work may be stated to be : — 

First. To give in as concise a manner as possible a 
description of the most available agents that may be 
successfully and safely employed as anaesthetics. 

Second. To present the chief chemical tests of the 



IV PREFACE. 

purity of each substance considered, with its composi- 
tion, physical characters, and medical properties. 

Third. To exhibit the best methods of administering 
the various anaesthetics, to give careful directions, and 
to state the precautions to be taken to avoid risk to the 
life of the patient. 

Fourth. To note the personal experience of the author, 
his assistants and friends, with the various forms of an- 
aesthetics and inhalers in use, with a selection of the 
most approved of them ; not withholding, however, the 
objections and experiments of other reliable investi- 
gators. 

Fifth. To compare the relative mortality from all the 
anaesthetics now employed, endeavoring to assist the 
reader in forming a fair and candid opinion on this most 
important subject, which is now and has for so long a 
period occupied the attention of the public as well as of 
the medical profession. 

To conclude are added practical hints on Local 
Anaesthesia, the use of the various Anaesthetics in the 
practice of medicine ; the Medico-Legal Nature and 
Importance of Anaesthetics; with a brief History of 
the discovery of Artificial Anaesthesia. 

1502 Walnut Street, 
March, 1878. 



CONTENTS 



INTRODUCTION. 

Anaesthetics of the Ancients ...... Page 13 

List of the Principal ngents that will produce anaesthetic sleep 16 

CHAPTER I. 

General anaesthetics — Alcohol — Ether. Mixtures of alcohol and ether. 
Methylic alcohol for inhalation ; mode of action the lightest and least 
injurious; its resemblance to chloroform. Varieties of ether, chemical 
tests, and mode of preserving in hot climates. The ordinary method 
of administering ether : towel, cone, sponge, or bag. Test when the 
patient is fully under its influence, with cautions in regard to solid 
food before etherization. The three stages of etherization. Peculiar 
effects of ether in the first stage ; observations by Dr. J. F. B. Flagg. Use 
of ether in ophthalmic surgery ; views of Dr. Carter of London. Ether 
inhalers — Hawksley, Cheatham, Lente, Allis — Experiments with Dr. 
Allis' inhaler. Experiments of Dr. D. Webster in Manhattan Eye and 
Ear Hospital, New York, with the cone of newspaper. Experiments 
with ether by the late Dr. J. Morgan, of Dublin, with his ether in- 
haler. Experiments of Mr. Morgan, of London, and Surgeon-Major 
J. II. Porter with the same form of inhaler. Ether inhalers of Dr. B. 
IV. Richardson, of Dublin, Dr. Angrove and J. T. Clover, of London 

Page 17-39 

CHAPTER II. 

Sulphuric Ether, not altogether free from danger, always gives warn- 
ing. "What to do in case of alarming symptoms when employing ether 
as an anaesthetic. Use of air, artery forceps, artificial respiration in 
fainting, inversion of the body and head, application of stimulants, 
in case of blood, food or ether entering the trachea or bronchi. 
Statistics in reference to death from ether, I r. Andrews, of Chicago, 
Dr. Richardson, of London. Recent cases of reported deaths collected 
by the writer. Mr. Lawson Tait on the advantages of boiling anhy- 
drous ether. Examination of the Royal Medical Chirurgical Society, 
of London, into the comparative merits of ether and chloroform. 



VI CONTENTS. 

Experiments with ether, with illustrations, by the sphygmograph, 
and conclusions by the late Dr. Morgan, of Dublin. Case of appa- 
rent failure of the heart's action, during the inhaling of ether, with 
recovery. Primary and secondary effects of ether. Reports of deaths 
from ether, by Drs. Holmes, A. Matthewson, G. M. Lowe, Shreve, T. 
G. Morton, and Saundly. Abstract of the report of the Boston Com- 
mittee on the alleged dangers from ether. Infl;immability of ether. 
Conclusions of the author in regard to ether . . Page 40-64 

CHAPTER III. 

Mixtures of Ether and Chloroform ; Dr. Washington L Atlee on. Death 
of a lady in Boston under Dr. Eastham, a dental surgeon of that city. 
Coroner's jury under charge of Dr. Ainsworth. Autopsy by Dr. Fitz, 
pathologist to the Massachusetts General Hospital. Methylic ether, 
its safety and best method of employment, by Dr. B. W. Richardson, 
of London ; also Dr. Carter's opinion, and Dr. Jones's, of Cork. Use of 
bichloride of methylene, by Dr. Spencer Wells, at Samaritan Free 
Hospital ; his doubts about its composition. Dr. Taylor's statement 
that it is a mixture. Report of five cases of death from this com- 
pound. Amylene ; introduction and use by Dr. Snow. Bromide of 
ethyl or hydrobromic ether, chemical composition and properties; 
experiments with frogs, rabbits, dogs, etc., by "Rabuleau." Mode 
of preparation Experiments of the writer on frogs and man. Its 
use in the ear, etc. ....... Page 05-80 

CHAPTER IV. 

Chloroform, chemical composition, impurities, tests. Recent investiga- 
tions, by Bowditch, of Boston. Deaths from chloroform in England. 
Aid of the legislature to stop the employment of chloroform in France. 
Mode of use in Scotland, by Professor Macleod, with form of apparatus, 
and all the necessary precautions in case of impending death. Report 
of twenty-one cases of chloroform administration. Dr. Allis' Chloro- 
form Inhaler. Employment of anajsthetics in labor. M. Pichard. 
Congress at Geneva. Drs. Lusk, Wilson, and Smith. Statistics of 
death from chloroform, by the late Dr. Morgan, of Dublin. Dr. Sims 
on Nclaton's method. Nitrite of umyl as an antidote to chloroform. 
Observations and cases, by Drs. Richardson, Burrall, Lane, and 
Munde. Dr. Clover's inhaler. Mixed narcosis, use of morphia 
before inhalation cf chloroform. Dr. Richardson's experimentation 
upon reported deaths from chloroform, etc. Conclusions in reference 
to the use and safety of chloroform, by Drs. Chisholm, Erichsen, and 
Gross Page. 80-111 



CONTENTS. 



CHAPTER V 



Original observations and experiments with Hydrate of Chloral. Liebreich 
on the impurities of chloral in cakes, test of purity, etc. Experiments 
of Dr. John A. Campbell at Garland Asylum, Carlisle. On chloral as 
an anaesthetic in children, by Dr. Bouchut, of Paris. M. Couty, of 
Paris, on death from chloral. Prof. Ore, of Bordeaux, venous injec- 
tions of chloral. Dr. J. M. Futhergill, of London, on the great utility 
of strychnia in chloral poisoning. Case of death from the use of chloral, 
and post-mortem appearances. Drs. Taylor and Tuke's opinions upon 
the effects of the long-continued use of chloral. The use of chloral 
for a Jong period with no serious results. . . . Page 112-129 

CHAPTER VI. 

Nitrous oxide gas as an anaesthetic. Practical observations and experi- 
ments of Dr. J. D. Thomas. The Thomas inhaler, description and 
mode of use. Mode of manufacturing nitrous oxide for inhalation. 
Impurities and mode of purification. Mode of administration Use of 
prop in extracting teeth, while under its influence. Risks, and treat- 
ment of accidents. Coxeter's form of cylinder for liquid nitrous 
oxide Page 129-138 



CHAPTER VII. 

Physiological action of nitrous oxide gas. Resemblance between the 
effects produced by nitrous oxide and asphyxia. Summary of the 
facts bearing on this subject. Not merely a passive agent. Dr. 
Evans' (of Pari?) experiments with nitrous oxide and other gases, 
and his conclusions Dr. J. II. McQuillen's experiments in 1868. and his 
repeating them in conjunction with the writer. Personal experiments 

• of Dr. Jeanne! in 1S69 ; he dwells upon the non-fatal character of 
nitrous oxide, and the rapidity with which its effects pass away. 
Also the corroborative experiments of M. Limouzin. Original ex- 
periments of Dr. Robert Amory in 1870, with his conclusions, 
and opinions of Dr. Johnston. Mode of action of anaesthetics. Ex- 
periments of Professors Heinrich Ranke and D. C. Binz on morphia, 
chloral, ether, chloroform, amylene, bromoform, and bromohydrate. 
Physiological action of nitrous oxide gas, by the editor of " Binz's 
Therapeutics." List of auttnrities on the nature and action of chloro- 
form, ether, and nitrous oxide. Deaths from the inhalation of nitrous 
oxide. Post mortem changes, etc. .... Page 139-160 



Vlll CONTENTS. 



CHAPTER VIII. 

J. F. Clover's improved apparatus for the combined use of nitrous oxide 
gas and ether. On the prevention of accidents from their use, and 
how to treat them successfully. Dr. F. N. Otis, of New York : his 
opinion of this inhaler. Death under the administration of ni- 
trous oxide and ether. Sir Henry Thompson, of London ; successful 
use of these agents combined. Inhaler of Colman and Shurtleff, of 
Boston, for the use of nitrous oxide or ether combined or for each. 
Dr. J. D. Thomas's experiments with this inhaler. Letter of defence 
of Codman and Shurtleff. Bonwill's method of anaesthesia produced 
by rapid breathing of atmospheric air . . . Page 161-172 



CHAPTER IX. 

Ether, its local application in the form of spray. Rhigolene. Dr. Lata- 
mendi's new method of utilizing the anaesthetic effects of ether spray. 
Anaesthetic mixture of ether and camphor. Excision of cancer of 
the breast by scissor-cutting under ether spray. Extract of eucalyp- 
tus as a local anaesthesia in dental operations. Snow, ice, and salt. 
Carbolic acid. Sulphate of morphia applied to sound skin, also when 
the epidermis has been removed .... Page 172-183 



CHAPTER X. 

An abstract of the therapeutic employment of chloroform and ether, 
alone and in combination, of chloral hydras, and of butylchloral in 
practical medicine Page 183-195 

CHAPTER XI. 

Medico-legal relations of anaasthetios. Case in Philadelphia of a sur- 
geon dentist. The important question, whether chloroform can be 
administered for criminal purposes; cases in France, England, and 
the United States. Dr. N. L. Folsom, R. M. Denig. Ethers as poisons. 
Experiments of A. Martin Ewald, llitzig, C. Bernard and Binz. 
Ether intoxication. Cliloroform ; its action as a poison, with the 
treatment Page 195-207 

APPENDIX. 

Discovery of thk Aiit of Artificial Anesthesia . Pa«e 2C8 



ARTIFICIAL ANESTHESIA 



INTRODUCTION. 

ANESTHETICS OF THE ANCIENTS. 

The ancient Greeks, it is stated, possessed a plant 
called mandrake. It belonged to the same family of 
plants as the belladonna, or deadly nightshade. From 
the root of this plant was extracted, by means of wine, 
a narcotic which was emploj'ed by them as an anaesthetic. 
Lucius Apuleius, who lived about 160 A. D., and of 
whose works eleven editions were republished in the 
fourteenth and fifteenth centuries, says " that if a man 
has to have a limb mutilated, sawn, or burnt, he may 
take half an ounce of mandragora wine, and whilst he 
sleeps the member may be cut off without pain or sense." 
To prove that this was true, Dr. B. W. Richardson, of 
London, after a lapse of five centuries, obtained a fine 
specimen of mandragora root, and made mandragora 
wine, and tested it, and found it was a narcotic, having 
precisel} T the properties that were anciently ascribed to 
it. He found that in animals it would produce even the 
sleep of Juliet, not for thirty or forty hours, a term that 
must be accepted as a poetical license, but .easily for the 
four hours named by Dioscorides, and, on awakening, 
there was an excitement which tallied with the same 
phenomenon that was observed by the older physicians. 
Another fact was noticed by the ancients, that many 
volatile substances acted more promptly by inhalation 
than by the stomach, and this form of medication was 
employed in Greece, Rome, and Arabia. By their pub- 
lished works, the knowledge of these facts was extended 
to other parts of the world. 

In China, in ancient times, the word ma-yo meant not 

9 



14 ARTIFICIAL ANESTHESIA. 

only Indian hemp, but anesthetic medicine; other sub- 
stances besides hemp entered into these benumbing 
recipes, such as the datura, a solanaceous plant, probably 
identical with the atropia mandragora; also aconite, 
hyoscyamus, etc. Some of these drugs form constitu- 
ents of the formula said to be employed by kidnappers 
of children, and robbers, and are therefore naturally for- 
bidden in China, at the present, to be sold or employed. 

The Indian hemp, under the name bhang, was exten- 
sively used by the Mohammedans and others in Central 
Asia. The most wonderful properties are ascribed to 
it. " Taken in excess, the spirits and demons maybe 
seen ; it confers prophetic powers ; it is sometimes taken 
by persons wishing to indulge in spiritualism, and it is 
used as an antidote to forgetful ness." (Dudgeon). 

A strong impulse was given to the study and applica- 
tion of the "different kinds of airs and gases " by the 
discovery of oxygen by Priestley and Scheele, in the 
middle of the last century, and numerous experiments 
were made by physicians with it. Another still more prac- 
tical result was obtained by Sir Humphry Davy, and 
published in 1800. u That nitrous oxide appears capa- 
ble of destroying physical pain, and may be used with 
advantage during surgical operations.' 7 This valuable 
and practical suggestion remained without fruit for a 
long time, and the surgeons, physicians, and accoucheurs 
still employed alcohol, in some form, or opium and its 
salts, to deaden as far as possible the sensibility to pain 
during their various operations. It was not until 1844 
that an effort was made in the United States to make 
Davy's discoveiy useful. But the crowning result was 
obtained in 1846 by Dr. Morton in the Massachusetts 
General Hospital, where it was demonstrated success- 
fully that the inhalation of "ether" was capable of so 
deadening the sensibility of the nervous system, that 
any operation, no matter how painful, could be per- 
formed, and the patient not suffer from its effects. It 
was also proven that ether was safe, and not at all like 
the wine of that insane root which, says Macbeth, 

" Takes the reason prisoner. 
And in this borrow'd likeness of shrunk death 
Thou shall remain lull two and forty hours." 



INTRODUCTION. 15 

This most valuable agent required but to be inhaled 
for a few minutes, when the patient, being in a pleasant 
frame of mind, would thus remain asleep, and after a more 
or less prolonged operation, u would awake and inquire if 
the diseased limb were still there, and could be told that 
the offending member was gone without his knowledge." 

No one can form, even at the present day, a just esti- 
mate of the true value of the various anaesthetics, or 
express in words their wonderful and extended applica- 
tion to the relief of human suffering. 

To the general surgeon it gives the opportunity of 
operating on grave cases of disease and injury, without 
which the death of the patient would be inevitable. It 
also affords, by the immediate relief from pain, the 
power to manipulate the broken or injured parts with 
facility, and thus obtain a correct diagnosis in the most 
obscure diseases and painful accidents. 

To the obstetrician and gynaecologist it is useful in 
assuaging the terrific pain of labor, and makes the 
dreaded instruments a blessing in disguise. In the diag- 
noses and treatment of abdominal diseases, it gives pre- 
cision and almost marvellous results, and in the removal 
of large masses or tumors great freedom from the dread- 
ful effects of shock to the nervous system. For the 
ophthalmic surgeon the anaesthetic reduces the sensi- 
bility of the eye so that it can be touched with impunity, 
and severe and dangerous operations can be performed 
upon this delicate and sensitive organ without pain and 
with much less risk. 

Again, in the,removal of foreign bodies from the eye 
or ear, particularly in children, by the use of the anaes- 
thetic all spasm is relieved, and the act is accomplished 
without injury. The profound sleep gives a most favor- 
able opportunity to the aural surgeon to perforate the 
membrana tympani, cut the minute tendon of the ten- 
sor tympani muscle, or perforate the mastoid cells. 

There are some thirty substances which are of so vola- 
tile a character, that they can be employed in producing 
anaesthesia. 



16 



ARTIFICIAL ANESTHESIA. 



The following is a 
List of the prin a' pal 



sleep :■ 

Nitrous oxide gas. 

Carbonic oxide gas.* 

Carbonic acid gas. 

Bisulphide of carbon. 

Light carburetted hydrogen 
(Hydride of methyl, or marsh 
gas.) 

Methylic alcohol. 

Methyl ic ether gas. 

Chloride of methyl gas. 

Bichloride of methylene. 

Terchloride of for my 1, or chlo- 
roform. 

Tetrachloride of carbon. 



agents that will 'produce ancestlictic 
carburetted hydrogen 



Heavy 

gas. 

(defiant gas or ethylene.) 
Ethylic, or absolute ether. 

(Sulphuric ether.) 
Chloride of ethyl. 
Bichloride of ethylene. 

(Dutch liquid.) 
Bromide of ethyl, or hydrobro- 

mic ether. 
Hydride of amyl. 
Amylene. 
Benzol. 
Turpentine spirit. 



Those anaesthetics which are emplo} T cd in the practice 
of medicine may be reduced in number at the present 
day to about four or five, namely — alcohol, ether, 
chloroform, and nitrous oxide. These can be employed 
alone or mixed in various proportions. They can be 
reduced to a still smaller number, viz., nitrous oxide gas^ 
and alcohol of various grades of power, as each of the 
eleven alcohols will by the chemical action of an acid 
produce its ether or chloroform. 



* Carbonic oxide has been used as a local anaesthetic to can- 
cerous or raw surfaces; but, when inhaled, it is a powerful nar- 
cotic poison. Owing to its superior affinity, it displaces the 
oxygen in the red blood-corpuscles, and uniits them for the func- 
tions of respiration. 



GENERAL AN/ESTJI ETTCS. \1 



CHAPTER I. 

General anaesthetics — Alcohol — Ether. Mixtures of alcohol and ether. 
Methylic alcohol for inhalation ; mode of action the lightest and least 
injurious; its resemblance to chloroform. Varieties of ether, chemical 
tests, and mode of preserving in hot climates. The ordinary method 
of administering ether : towel, cone, sponge, or bag. Test of the pa- 
tient when fully under its influence, with cautions in regard to solid 
food before etherization. The three stages of etherization. Peculiar 
effects of ether in the first stage; observations by Dr. J. F. B. Flagg. Use 
of ether in ophthalmic surgery ; views of Dr. Carter of London. Ether 
inhalers — Hawksley, Cheatham, Lente, Allis — Experiments with Dr. 
Allis' inhaler. Experiments of Dr. D.Webster in Manhattan Eye and 
Ear Hospital, New York, with the cone of newspaper. Experiments 
with ether by the late Dr. J. Morgan, of Dublin, with his ether in- 
haler. Experiments of Mr. Morgan, of London, and Surgeon-Major 
J. H. Porter with the same form of ^inhaler. Ether inhalers of Dr. B. 
W. Richardson, of Dublin, Dr. Angrove and J. T. Clover, of London. 

It has long been recognized as a fact, that, when per- 
sons are under the controlling influence of alcohol, either 
in the form of wine, gin, whiskey, or brandy, they may 
be cut, bruised, or even have their bones broken, with- 
out expressing, or experiencing, much, if any, pain. Al- 
cohol was very early emplo3 r ed by surgeons to produce 
immunity from the pain of the knife, long before anj T true 
anaesthetic was discovered. Indeed we find that a small 
portion of brandy or whiskey given prior to the admin- 
istration of any anaesthetic agent is found to facilitate 
the action of the agent employed. 

Dr. John Lynk* predicts that alcohol will, by the close 
of the next decade, rank first as an anaesthetic. He states 
that he has long employed it in this capacity, and he is 
gradually learning to appreciate it more and more, until 
he now depends upon it almost entirely in his surgical ope- 
rations. He has not as yet tried it in a capital operation, 

* Cincinnati Lancet and Observer, May, 1876. 
2* 



18 ARTIFICIAL ANAESTHESIA. 

but has employed it, in the proportion of about one pint, for 
a strong adult, in tablespoonful closes eveiy twenty min- 
utes in an amputation of the finger, extraction of teeth, 
in a case of severance of the posterior tibial nerve, with 
the use of chloroform ; also ligation of radial and ulnar 
artery, in which he only used two drachms of chloro- 
form, and one pint of whiskey. This latter operation he 
thinks served to demonstrate the value of the whiskey 
as an anaesthetic, leaving the other functions, especiall}' 
the heart, in a more normal condition than by the chlo- 
roform alone, which, he states, was proven by the strong 
pulsations of the heart after the chloroform had been 
withdrawn. 

A mixture of chloroform and alcohol, known as the 
compound spirit of chloroform of the London Phar- 
macopoeia, has been employed by many other surgeons 
with more or less success. Another mixture is employed 
at Guy's Hospital, when chloroform is not well borne, 
by first bringing the patient under the influence of the 
chloroform and then keeping up the ainesthetic effects 
by inhaling the following mixture : — 

R. Alcohol, fgj. 

Chloroform, l.S'j- 

Sulphuric ether, i' .5 iij. — M. 

The late Dr. E. Sansom preferred a mixture of — 

R Chloroform. f £ij. 

(Absolute alcohol), f 5 ij. — M. 

B3* careful experimenting with these and various com- 
binations of chloroform and alcohol, I have always found, 
that, when such mixture was poured upon an inhaler, 
the most volatile spirit will arise first, then the next, and 
so on, leaving the least easily evaporated upon the in- 
haler; this fact should always be borne in mind: that 
in all these compounds we must employ all the precau- 
tions to be observed in the use of chloroform alone. 



Methylie Alcohol. 

Ordinary alcohol is an organic radical called ethyl, 
which is obtained by the distillation of rye, barley, or 



METHYLIC ALCOHOL. 19 

wheat whiskey. Thus obtained it is a clear liquid con- 
taining more or less water, which, by redistillation in 
conjunction with lime, becomes what is known as abso- 
lute alcohol. There are two other alcohols which are 
found in commerce, one called metl^lic, and the second 
amylic alcohol. The methylic alcohol is obtained by the 
dry distillation of wood, and the amylic b} r the distilla- 
tion of potatoes. They are both used for adulteration 
and for commercial purposes. Methylic alcohol, py- 
roxic spirit, or wood spirit, as this has been differently 
called, has been known for about sixty-two years, and 
when analyzed by Messrs. Dumas and Peligot, it was 
found to contain 37.5 per cent, of carbon, 12.5 per cent, 
of hydrogen, and 50 per cent, of ox} 7 gen. When pure 
it remains clear in the atmosphere. It has an aromatic 
smell and taste, with slight acidity, and boils at 140° 
Fahr. According to the experiments of Dr. B. W. Rich- 
ardson, of London, this alcohol, owing to its volatile 
nature, may be exhibited freely by inhalation, in the 
same manner that chloroform is administered. It then 
enters the blood by being carried with the air that is 
inspired into the pulmonary tract, and thus into the air 
vesicles. Here it is absorbed into the circulation by 
the minute bloodvessels which make their way from the 
heart through the lungs, and which ramify upon the vesi- 
cles. By administrating the vapor of methjlic alcohol 
in this way, its effects are rapidly developed, for it con- 
denses quickly in the blood, is carried rapidly into the 
left side of the heart, and thence is distributed by the 
arteries over the whole body, as quickly as can be con- 
densed and absorbed. 

This alcohol is recommended by Dr. Richardson, and 
he has obtained better results from its use than from the 
heavier or ethylic spirit. It is much more rapid in its 
action, and much less prolonged in its effects than com- 
mon alcohol, and, what is of more importance, it de- 
mands the least possible ultimate expenditure of animal 
force for its elimination from the body. According to 
the same authority the lighter the alcohol therefore, 
ceteris paribus, the less injurious its action. When in- 
haled, its effects are developed in four distinct stages. 

First stage, there is excitement, flushing of the body, 



20 ARTIFICIAL ANESTHESIA. 

and dilatation of the pupils, after a time there follows 
languor, and the muscular movements become irregular. 
Second stage, muscular prostration, and labored breath- 
ing, attended by deep sighing movements and rolling over 
of the body. 

Third stage, complete insensibility to pain, with un- 
consciousness to all external objects, with inability to 
exert any voluntary muscular power. The breathing 
now becomes embarrassed and blowing, with bronchial 
rales, due to the passage of air through fluid that has 
accumulated in the finer bronchial passages. The heart 
and lungs, however, even in this stage, retain their func- 
tions, and therefore recovery will take place if the con- 
ditions for it be favorable. Also, if the body be touched 
or irritated in parts, there will be a response of motion, 
not from any knowledge or consciousness, but from reflex 
action. During all these stages there is no violent con- 
vulsive action, but step by step a reduction of tempera- 
ture, so at last the loss of heat will become dangerous, 
for the cool body cannot throw off the water freely, and 
therefore fluid collects in the lungs and there is a risk 
of suffocation, as from drowning. If the administration 
of the methylic spirit be continued when the third de- 
gree has been reached, there is a last stage, which is that 
of death. The two remaining nervous centres which 
feed the heart and respiration cease simultaneously to 
act, and all motion is over. If, however, after the third 
stage of insensibility, the administration of methylic 
spirit be stopped, recovery from the insensibility and 
prostration will invariably take place on one condition, 
that the body be kept warm for seven hours.* 

There is but little doubt that this sudden reduction 
of temperature is one cause of death after the administra- 
tion of ether and chloroform. The patient is apparently 
all right, and is transferred to the ward from the warm 
operating room, no special means are employed to keep 
up the temperature, and gradually the patient sinks into 
an unconscious state, from the fluid which collects, and 
dies from congestion of the lungs, the result of neglect. 

* On Alcohol. A course of six Canton Lectures, delivered 
before the Society of Arts (London, 187;"), by Benj. W. Richard 
son, M.A., M.D., P.R.S). 



ETHER — ETHYL OXIDE. 21 

By the action of acids upon the alcohols, causing the 
dehydration or removal of the water which they contain, 
various ethers are formed. 

ETHER— ETHYL OXIDE (C 4 H 5 0— C 4 B 10 O). PURITY 
AND CHEMICAL TESTS. 

The ordinary ether sold has a specific gravity of 0.750 ; 
when shaken with an equal quantity of water it loses 
J of its volume. Ether fortior should have a sp. gr. 
of 0.728, and will not, when shaken with an equal bulk of 
water, lose more than \ of its volume. If pure, ether 
will not redden litmus paper. 

The specific gravity of chemically pure ether is 0.713 
—0.725, and its boiling point 95° F. A test tube filled 
with it and held in the warm hand, should boil on the ad- 
dition of fragments of broken glass. In hot countries, like 
India and our own, or in the close wards of a hospital, 
if preserved in imperfectly stoppered bottles, ether will 
absorb oxygen, and forms acetic acid, and becomes im- 
pure, mixing with water in large proportions ; unsuitable 
for inhalation. 

Ether does not mix with water, but is slightty soluble 
in it ; it mixes readily with alcohol.* 

The ordinary method in use of administration of the 
first discovered anaesthetic, namely, washed sulphuric 
ether, is as follows : — 

An inhaler is made by folding a towel into a large 
cone or bag, and then placing a coarse sponge in its 
apex. Ether is then poured upon it with a free hand — 
half an ounce or more at a time — and repeated as neces- 
sary by removing the cone from the patient's mouth to 

* The ether which is most generally employed in Philadelphia, 
and, indeed, throughout the United States, is that manufactured 
by the reliable firm of Powers & TVeightman, and it is uni- 
formly of most excellent quality. Occasionally the ether of Dr. 
Squibb, of Brooklyn, N. Y., is resorted to ; it is of higher price 
and is freer from water, and, we think, is more apt to produce irri- 
tation if used too freely ; this can be obviated by moistening with 
warm water the sponge cone, or inhaling apparatus. If in doubt 
about the purity of your ether, agitate it with lime-water and then 
decant it before using. 



22 ARTIFICIAL ANAESTHESIA. 

renew the supply of ether. The lower part of the face, 
mouth, and nose is covered with the cone so as to ex- 
clude most of the air, and allow the patient to fill his 
lungs with more or less diluted ether vapor, depending 
on the care with which the cone is applied. There will 
be, at the beginning of the inhalation, attempts to strug- 
gle, on account of the irritating nature of the ether, which 
are to be gently, but firmly restrained, using as little force 
as possible, and only one or two inspirations of pure 
air allowed; subsequently complete quiescence usually 
follows, and the patient passes into a profound state of 
insensibility. If, however, the face become livid or 
very pale, the cone is lifted entirely away for a time until 
this condition disappears. In delicate persons, it is well 
to notice any unusual slowness or intermittence in the 
condition of the pulse. One of the best tests of the 
patient being fully under the influence of the ether, is 
when the conjunctival surface of the eyo can be touched 
with impunity, and the arm can be raised and will fall 
as if paralyzed. Dr. Snow states that he found the eye 
sensible to light in all stages of etherization. 

Ether should not be inhaled immediately after a full 
meal, indeed it is better to take only a biscuit or cracker 
and a glass of wine or a teaspoonful of brandy and 
water, or a scruple of bromide of potassium in water, half 
an hour before, always avoiding the risk and annoyance 
of a full stomach for several hours previously. Nothing 
like hard boiled eggs, ham, or beef should ever be allowed 
a feeble patient before inhalation for twenty-four hours. 
If nourishment is necessary, let it be of a liquid character, 
as solid food, not digested, has been the cause of death 
in more than one person. 

Perfect quiet should be enjoined on all around the 
patient, as noises, or even loud talking, interfere with 
the perfect and rapid action of the anaesthetic. Nothing 
like a tight band or garment should prevent the free 
action of the throat, chest, or interfere with the muscles 
of respiration. False teeth should always be laid aside 
until after the inhalation is over. 

It is always well to bear in mind that there are three 
well-marked stages of etherization : 1. That of muscular 
relaxation; 2, tetanic or slight convulsive action; 3, 



ETHYL OXIDE. 23 

complete loss of sensibility, with snoring, and muscular 
motion ; unless this latter stage is reached there is not 
full insensibility to pain. 

A peculiar effect of etherization, which has been early 
noticed and published* by a careful writer and experi- 
menter of this city, Dr. J. F. B. Flagg, and which re- 
sult has been confirmed by us and by others, is stated 
as follows : — 

" There is a particular point of etherization, which, if 
improved at the moment (slight operations can be per- 
formed) will leave the patient in full possession of all 
his faculties with the single exception of the sense of 
pain, and particularly the consciousness of touch is as 
acute as under ordinary circumstances, if not quickened." 

In our own experiments the sense of sound was always 
very active, and Dr. Thomas takes advantage of this by 
having a musical box playing during the action of nitrous 
oxide, so as to make a pleasant impression on the patient. 
If, however, the patient is roused from his first anaesthe- 
tic sleep by the pain of the knife, or a sudden noise, or a 
rough touch, we have always found it more difficult to 
cause such a patient to pass into a profound state of 
insensibility by means of the ether. Yet, if a patient 
will not breathe the ether properly when it is required 
for an operation, it will sometimes do good to prick or 
scratch the surface with a knife and then insist upon the 
patient breathing the ether so as to get rid of the pain. 
Some patients suffer at the time from tinnitus aurium, 
or buzzing noises in the ear, and some have these sj^mp- 
toms some days after etherization. 

Almost all American surgeons employ ether in the 
various operations, even for the most delicate, viz., on 
the eye and ear. In Great Britain and Ireland, the sur- 
geons for a time employed chloroform to the almost en- 
tire exclusion of ether, but within the last few years the 
subject of the greater danger in the use of chloroform 
has excited much attention, and many of them have 
changed their views since the visit of Dr. B. J. Jeffries, of 

* Ether and Chloroform. Their employment in surgery, den- 
tistry, midwifery, therapeutics, etc. By J. F. B. Flagg, M.D., 
Surgeon Dentist. Philadelphia, Lindsay & Blakiston, 1851, p. 89. 



24 ARTIFICIAL ANAESTHESIA. 

Boston, during the International Opbthalmological Con- 
gress in London, 1872.* Dr. Carter, the distinguished 
ophthalmic surgeon of St. George's Hospital, London, 
has, he states, since that time emplo} r ed ether with per- 
fectly satisfactory results as regards the (spasm) of the 
muscles, and without the appearance of an}' symptoms 
to indicate a possibly prejudicial action. In lieu of the 
folded napkin, he has substituted for some time a cone 
of thick felt covered with water-proof tissue. 

He also states that he has employed with success the 
" Hawksley Inhaler." It consists of "a glass vessel ca- 
pable of holding ten ounces of ether, with an inlet valve 
for air, and its sliding tube is graduated in ounces for 
the purpose of measuring the quantity of ether consumed. 
A pipe conveys the vapor to the face-piece, the edge of 
which is surrounded by a water cushion to secure exact 
adaptation. There is also a shutter valve for regulating 
the admission of air, either at the beginning of an opera- 
tion or during its course. It has also an additional pipe, 
furnished with a valve, which convoys the expired vapor 
to the floor." This latter is a useful addition, when em- 
ployed in a hospital where a large number of patients 
are to be etherized in succession, so that the ether is not 
diffused in the air around the operator. When in use, 
the vessel in which the ether is contained is immersed in 
water, heated to 100°, which promotes a more rapid and 
equable evaporation of the ether. " Ether boils at about 
90°; but before the quantity contained in the vessel has 
reached that point, the temperature of the surrounding 
water will have fallen." This is a valuable inhaler; it is 
too complicated for every -day use by the physician or 
surgeon, but will be found very useful in large hospitals, 
and cause a areat saving in the amount of ether em- 
ployed. 

* Re-introduction of Ether into England. By B. Joy Jeffries, 
M.D. Reprinted from " Boston Medical Journal" of October 3d, 
1872. 



Cheatham's ether inhaler. 



25 



Cheatham's Ether Inhaler. 

This operates by Lente's method of replenishing the 
evaporating surface without removing it from the face. 
A patient cannot be etherized as quickly with it as with 
the common cone, but with much less ether, and by it 
you avoid the disagreeable effects of having the ether 
permeating ever}' part of the office or house in which it 
is used. Its convenience of application is also quite ob- 
vious. The ease with which the face-piece (being paper) 
can be removed immediately after use and thrown away 
is, I think, a strong recommendation in its favor. 

The apparatus consists of a tin cup (Fig. 1, a) holding 

Fig. 1. 




in the inside a sponge as an evaporating surface, and 
connected from the top by rubber tubing with the bottle 
that contains the anaesthetic. This tube has attached to 
its distal end a cap, d, that will fit over the neck of al- 
most any bottle, thus doing away with Lente's graduated 
bottle. 

Mode of using the Inhaler. — Make a cone of paper, 
cut the top off, so, when the tin cup, a, is slipped inside 
the top of the cup, it will protrude a line or two from 
the top of cone. Place tin cup, b, over both cup and 
cone, screw it down tightly by means of nut, c, and you 
have the cone held tightly. Attach tube to top of cup, 
and the apparatus is complete. The smaller the cone, 
the more quickly you can get the patient under the in- 
fluence of the anaesthetic. I would suggest after the cone 
3 



26 



ARTIFICIAL ANAESTHESIA. 



is in position, the bottom should be trimmed, leaving a 
part of it (we shall call it the back part) that is intended 
to go over the chin, three inches longer than the cup, 
and sloping forwards and upwards, leaving the front 
part, intended to go over the nose, about an inch longer 
than cup. e gives an inside view of cup, A. 

These various forms of Inhalers arc made by George 
Tiemann & Co. of New York; also Gemrig, Snowden, 
or Kolbe, instrument makers, of this city, and by Cod- 
man & Shurtliff, of Boston. 



Fi ? . 2. 



Dr. Lente's Ether Inhaler. 

As early as 1866, Dr. Lente invented a form of inhaler, 
but which has recently been modified (see Fig. 2). The 

present improved instrument 
resembles very much the face 
piece of " Waldenburg's" ap- 
ratus for the inhalation of 
condensed and rarefied air. 
The idea of using sheet brass 
and the india-rubber air- 
cushion was taken from it. 
The air-cushion, however, 
proved a failure, and the in- 
ventor substituted hair for 
stuffing the cushion, which he 
states retains suflicient of its 
rotundity to lit the face air- 
tight. 

Mode of employing this 
form of Inhaler. — A piece of 
sheet lint is stuffed into the 
cone, a piece of wire or whalebone is slipped in, so as to 
keep the lint in place and prevent its touching the face. 
The lint is saturated with ether and placed over the face. 
There is an opening, fitted with a cork stopper at the 
apex, large enough to admit air. This is usually closed, 
but, if it is found necessary, the stopper can be removed. 
The ether can be poured in at this opening without re- 
moving the apparatus from the patient's face. Its clean- 
liness is perfect, as a different piece of lint ought to be 




ALLIS 7 ETHER INHALER. 



21 



employed each time. My assistant at Howard Hospital 
has experimented with this form of apparatus, and found 
it satisfactory in administering ether as an anaesthetic. 



Dr. Allis' Ether Inhaler. 

In operations upon the eye and ear in the same insti- 
tution, the inhaler we have chiefly employed is that de- 
signed b}' our colleague, Dr. O. H. Allis, of this city, 
whose experience in this department, both jn the use of 
ether and chloroform, has made him an authority on the 
subject. The apparatus has been described and exhibited 
before our various medical societies (see Fig. 3). It con- 
sists of a wire frame work suf- 
ficiently large to cover the 
lower part of the face ; these 
wires are parallel and about 
one-quarter of an inch apart. 
Between the wires, and from 
side to side, a strip of muslin 
bandage, two and a half inches 
wide and three yards long, is 
passed (see Fig. 5). The wire 
frame is five inches long and 
three inches at its greatest 
width. Outside of the wire 
frame there is a covering of 



sheet brass, and over this a 

patent leather cover, with a 

cushioned edge to fit, over the 

face, covering both the nose 

and mouth. When ready for use the top is left open for 

the free entrance of air and for supplying the ether from 

without. 

Each section of the bandage is separated from the ad- 
joining one, thus permitting the air and ether to pass 
freely on both sides of it. The ether is supplied from a 
bottle with a glass dropper. 

Placing the apparatus over the face, a small portion of 
ether is gradually dropped at a time until deep inspira- 
tions are noticed, when it is poured in, and, in doing so, 
we should be careful to watch it so as not to irritate the 
larynx. 




28 ARTIFICIAL ANiESTHESIA. 

The objections to this form of apparatus are: 1st. 
That the exhaled vapor is not conveyed to the floor, but 
is diffused in the air, to be breathed by the operator and 
his assistants. For a single operation, this is not of 
much importance, but where there are a number of cases 
the arrangement is not conducive to the comfort of the 
operator. 

2d. The bandage of muslin across the bottom becomes 
clogged with saliva, and at times by discharges from the 
stomach, and cannot be readily removed. 

3d. Owing to the peculiar arrangement of the muslin 
strips, it is tedious and difficult to remove or replace them. 

In a conversation with Dr. Allis, he stated that he 
considered the chief merit of his instrument was, that 
it thoroughly and instantaneously liberated the ether, 
and that while there was not the least impediment to 
respiration, yet all the air was impregnated with the 
anaesthetic. 

Neither ether nor chloroform can be inhaled in the pure 
state. 

It is always atmospheric air, impregnated with the 
anaesthetic, that sustains life and produces anaesthesia. 

The expressions "give him nothing but ether, exelude 
the air," are only relative terms; they simply mean 
saturate the air as much as j)ossible with the ether. Per- 
mit the patient to have no fresh air, but compel him to 
breathe air charged with ether. 

Now r , in Allis' apparatus there is no chance for the 
ether to remain in its fluid state, but exposed as it is on 
a thin stratum of muslin, it yields its amesthetic princi- 
ple promptly. 

When he first employed his instrument, bj'standers 
would suggest that it be closed at the top, so as to per- 
mit no escape of ether. 

This will show that the true laws of ether were over- 
looked ; ether-vapor, while it will diffuse itself throughout 
an entire room, is of greater specific gravity than at- 
mospheric air and tends to the floor. 

To close this apparatus at the top, would necessitate 
ingress of air at the part surrounding the mouth, for 
air must be admitted. 

If it be excluded at the bottom and left open at the 

\ 



ALLIS' ETHER INHALER. 29 

top, the advantage of having a constant supply of ether 
dropping upon the folds is very great. 

Some suggested that the frozen moist vapor that is 
seen at the top of the instrument indicates a waste of 
ether, but the small quantity used and the rapidity with 
which anaesthesia can be effected, are complete refuta- 
tions of this. 

The untidiness can be entirely avoided with a little 
care. 

The instruments are now completed with a little draw- 
slip, the suggestion of Dr. W. W. Keen. 

This can be easily withdrawn, and a clean one substi- 
tuted. 

Dr. Allis' mode of using it is, first, to apply directly 
to the mouth and nose, but as soon as the first indica- 
tions of anaesthesia present themselves, he places a 
single fold of a coarse towel directly over the mouth 
and nose, and over this reapplies the apparatus. 

Ether and chloroform cause vomiting, hence both ne- 
cessitate the precaution of a basin and a towel, and if 
these are provided at the outset there will be less confu- 
sion, delay, and annoyance from troublesome emesis, at 
the critical moment of the operation. 

In regard to the trouble of removing and replacing 
the bandage, this certainly can be said, the operator can 
do it all himself, and does not require skilled labor to 
do it for him, by sewing the end of the bandage to a card 
and slipping it through in a few moments. 

Improvements have been made in this apparatus, by 
Mr. Snowden, of this city, which will be seen by the 
new illustrations even without a more minute descrip- 
tion. Fig. 4 shows the frame-work of metal, before ap- 
plying the bandage, Fig. 5 exhibits the mode of passing 
in the strip of muslin so as to give the large surface, 
yet not permitting the bandage to come together when 
wet with the ether. Fig. 6 shows the completed inhaler 
with its covering of patent leather arranged for use, and 
the drawing strings to draw it together if necessaiy. 
Fig. 7 shows the mode of using the completed apparatus, 
its application to the patient's mouth being protected 
by a towel or napkin placed across the chest in case of 
sickness of stomach, the mode of holding the inhaler and 

3* 



30 



ARTIFICIAL ANAESTHESIA, 



the use of the dropper, so that the inhaler is not re- 
moved from the patient's mouth when once placed there, 

Piff. 4. 




and yet the large evaporating surface is kept moist all 
the time until the patient is fully under its influence. 

Dr. G. II. Coburn, late resident physician of Howard 
Hospital, carefully recorded all the eases at my request 
oceurring during the years 1875-G, in which this form of 
Allis' inhaler was emplo3 T ed in the various surgical oper- 
ations performed in the institution. It was found by 
him that the shortest time required to produce complete 
anaesthesia in a young female patient was three minutes, 
and the amount of ether employed was only one fluid- 
ounce. The longest period required in an adult female 
was seven minutes, and the amount of ether used two 



ALLIS' ETHER INHALER. 



31 



ounces and a half. The doctor did not notice in any. of 
the cases but slight redness of the eyes. In a few instan- 



Fig. 5. 







ces there was a hysterical tendency among the females. 
If solid food had been taken, occasional vomiting would 
follow, but after liquid or light forms of nourishment, 
vomiting was very rare, not more than one in lift}* cases. 
In temperate males the time for full anaesthesia was 
from five and a half to eight minutes; ether consumed, 
minimum quantity, two ounces, maximum, three ounces. 
In one hundred cases of the administration of ether by 



ARTIFICIAL ANAESTHESIA. 



Dr. David Webster,* in the Manhattan Eye and Ear 
Hospital, New York, the average length of time occu- 

Fig. 6. 




pied in producing anaesthesia (with a newspaper cone 
lined with a towel) was 5.84 minutes. The shortest 

* Now York Medical Journal, August, 1872, p. 153. 



ALLIS' ETHER INHALER. 



33 



time recorded, one and a half minutes, which was in 
the case of a child; the longest was twenty minutes, in 



Fiff. 7. 




SNOWDEN 



which case the patient acted badly, the ether having to 
be "let up" from time to time, in consequence of his be- 
coming asphyxiated. Vomiting occurred in forty-two 
per cent, of the cases. The quantity of ether consumed 
was not noted. The doctor observes, "That the cone of 
newspaper should be short, so as to be as little as pos- 
sible in the way and in the light. It should be thick, so 
as not to be easily saturated with ether; for when the 
paper is wet through it cannot be made to retain its 
proper shape, but has an unpleasant tendency to collapse 
and asphyxiate the patient by direct contact with his 
nose." 



34 ARTIFICIAL ANESTHESIA. 

Of thirty patients, the last which the late Dr. J. Mor- 
gan, of Dublin, etherized by means of his inhaler, sick- 
ness of the stomach occurred only in two, and in these 
instances food had been taken one hour and a half be- 
fore operating. The inhaler invented by this distin- 
guished advocate of the use of ether, was a round box, 
filled with cotton, with a glass cover and an india rub- 
ber diaphragm at the top of the instrument moving at 
each respiration. The ether was inhaled through a flexible 
tube, to which is attached a mouthpiece to fit over the 
face. When about being used, pour in gradually two 
fluidounces of sulphuric ether, of s. g. 0.720 for an adult, 
but proportionate^ less for a child, and apply the mouth- 
piece so as to include the mouth and nose. Should the 
patient not yield in four or five minutes, pour in gradu- 
ally another two ounces, as more will seldom be re- 
quired. 

Dr. Morgan has comparatively tested the cone and 
sponge with the inhaler, and finds that the time is not 
only much longer in the first form of apparatus, but the 
effects also far less satisfactory both as to the temporary 
and after condition of the patient. 

Mr. Morgan, Surgical Registrar at St. George's Hos- 
pital, London, has suggested a modification of the felt 
cone ordinarily in use in this and other hospitals in Eng- 
land. 

"The instrument consists of a cone of felt, in the apex 
of which a piece of sponge is fixed, on which the ether is 
poured. This is fitted into a case of metal surrounded 
by an outer one of similar shape, but sufficiently large 
to leave a space between them through which the expired 
air can freely circulate before it escapes. There are two 
valves, acting in opposite directions: one admitting the 
air, which passes through the sponge moistened with 
ether ; the other, through which it escapes into the 
chamber between the two metal cones. The close appli- 
cation of the instrument to the face is secured by means 
of the india-rubber cushion, which is filled with air by 
the tap, so that all the air inspired must pass through 
the valve. The warmth produced by the air which cir- 
culates between the two cones prevents the ether on the 
sponge from freezing, and the vapor which escapes is 



morgan's and Richardson's ether inhaler. 35 

carried off by a tube to any distance which may be de- 
sired. The quantity of ether required in this apparatus 
is much smaller than in the ordinary cone; and the ad- 
vantage it thus possesses, as well as the safet}^ and free- 
dom from ether-vapor obtained by the administrator, 
render it superior to other similar apparatus. Several 
American surgeons, whose knowledge and experience of 
ether are generall} r recognised, have expressed considera- 
ble approbation of this invention. It is manufactured 
and sold by Messrs. Blaise & Co., 67 St. James's Street." 
The following results* were obtained by the use of 
Morgan's inhaler. 

Report of Experiments ivitli Ether in 21 and 26 Cases, f 

Minutes. Seconds. 

Shortest time taken to place a patient under the 

anaesthetic influence 3 30 

Longest time 24 

Average time 8 10 

Average time under influence . . . .19 6 

Smallest quantity of ether used in one case 2 ounces 4 drachms. 

Largest 9 " 

Average . . 5 " 1 " 

Vomiting occurred in 11 cases during or after the ad- 
ministration of the drug. Excitement occurred in 7 
cases to a marked degree during or after administration 
of the drug. (Does our experimenter mean resistance as 
excitement, or, if in a female, hysterical excitement?) 
The anaesthetic was invariably given on an empty stom- 
ach. The ether was given by Morgan's inhaler. Ether 
analyzed and found to be perfectly pure, s. g. 720.2 at 
64° Fah. 

Ether Inhaler of Dr. Richardson. 

In 1873 Dr. B. Willis Richardson,! of Dublin, designed 
and employed a simple form of ether inhaler for use in 

* Those who have used both the English and American ethers 
state that the former gives less favorable results than our washed 
ether, aether fprtior, U. S. P. 

f By Surgeon-Major Porter, Assistant Professor of Military- 
Surgery. London : 1875. 

X Description and Illustration of an Ether Inhaler, etc. By 
B. W. Richardson, F.R.C.S.l. John Falconer, Dublin, 1873. 



36 ARTIFICIAL ANESTHESIA. 

hospital practice. The ether box, of metal, has a capa- 
city of three ounces, with an oval air-opening half an 
inch long, and about an eighth of an inch from its upper 
margin. By rotating the lid, which has a similar shaped 
opening in its side, the admission of air can be easily 
regulated. At the beginning of the inhalation, the inner 
opening may be fully exposed and gradually covered. 
The ether box communicates with the face-piece by means 
of a tube an inch in length and one inch and a half in 
diameter, the ether-box opening of the tube being two- 
thirds closed by a fixed diaphragm. This prevents the 
fluid ether from passing into the tube when the patient 
is in the horizontal position. The face-piece opening of 
the tube has a diameter of one inch. The tube itself, in 
order to increase the evaporating surface, should be 
nearly filled with soft cotton candlewick, having, when 
in use, one end submerged in the fluid ether. The in- 
haler may be made of silvered copper or of block-tin, but 
the margin of face-piece should be formed of flexible metal 
and covered with morocco leather. 

"This inhaler the inventor states to be simple in form 
and moderate in price, and designed as a substitute for 
the towel and sponge, in the use of which there is much 
waste of ether, a matter in hospital economy that may 
be of some importance." 

Dr. Richardson has employed and prefers anhydrous 
sulphuric ether, because it was found to produce the 
most rapid ainesthesia. 

Dr. Angrove's Handy Ether Inhaler.* 

This gentleman states that in England there is a great 
want felt just at present for an effective, handy and cheap 
inhaler. He has endeavored to supply this want. His 
inhaler "consists of a cylinder, on which fits, by a bayo- 
net joint, a cap, around the rim of which are attached 
several stout wires. The top of the cap is perforated 
with holes, and through the middle is inserted a long 
metal tube reaching nearly to the bottom of the cylinder. 

* The Description of a Handy Etlicr Inhaler. By W. T. An- 
grove. House Surgeon to the Yarmouth Hospital. " London 
Lancet," March, 1877, p. 123. 



clover's ether inhaler. 37 

One end of an air-tight silk reservoir is fastened to the 
cap, and the other to the flexible tube, which is also at- 
tached to the mouth-piece. The flexible tube runs through 
the reservoir, and is directly connected with the metal 
tube. The inside of the cylinder is lined with felt, and 
a couple of turns of the same material are wound round 
the wires, thus presenting three surfaces for the evapo- 
ration of the ether. Having filled the reservoir with air, 
an ounce of ether is poured into the cylinder through the 
nozzle; this suffuses itself all over the felt. The mouth- 
piece is then applied to a patient; he is told to 'draw in 
his breath;' the vapor he inspires comes from the reser- 
voir, passes through the holes in the cap, over the evapo- 
rating surfaces of felt, and up through the whole length 
of tube; he expires the same vapor, which passes back 
to the reservoir, and becomes recharged with ether dur- 
ing the next inspiration. The inventor further states 
lie has completely anaesthetized several individual pa- 
tients in a little over one minute, one in forty seconds. 
An ounce of ether is sufficient to keep a patient about 
ten minutes." 

The cylinder is five inches high and three in diameter. 
The reservoir holds about a pint and a half. The length 
of the tube can be made according to taste. To show 
that they are still at sea in England in regard to ether 
inhalers, I will conclude this part of my subject by giv- 
ing a description of one of the latest invented, from the 
British. Medical Journal. 

The Portable Regulating Ether Inhaler of 
J. T. Clover, F.R.C.S. 

" In the British Medical Journal, of July 15th, 1876, 
I described an apparatus for giving laughing gas and 
ether, separately or combined. Experience in more than 
three thousand cases in which I have used it convinces 
me that the administration of ether may be made far less 
unpleasant to the patient, and equally effective and safe, 
by first giving enough gas to render the patient uncon- 
scious of its taste. 

"The arrangement of the apparatus enables one to 
cause the patient to breathe directly into and out of a 
4 



38 ARTIFICIAL ANAESTHESIA. 

hag, or parti}", or entirely, through a vessel containing 
liquid ether; and, even without gas, it is very efficient, 
inasmuch as it gives the power of varying and of sus- 
taining the strength of the vapor. I have used it a great 
many times without gas, and find it as safe as any other 
way of giving ether, whilst the risk of coughing and 
sickness is much lessened. 

"The plan of excluding fresh air until insensibility has 
been induced, and admitting it very sparingly afterwards, 
has now been extensively tried in various wa} r s, and, so 
far as I know, it is practically free from the danger of 
causing serious obstruction to the pulmonary circulation 
and overdistension of the right cavities of the heart. Of 
course, air cannot be indefinitely excluded, but the pulse 
and respiration give timely notice when air is required. 
A single artificial respiration of fresh air in these cases 
affords more relief than several such respirations when 
the apncea has resulted from an overdose of ether or 
chloroform. The reason for this is, that in the former 
case the symptoms depend chiefly on the want of ox3^gen, 
and in the latter upon the presence of a substance which 
has not only entered the blood, but has penetrated the 
tissues of the body. Jf the apparatus be overheated, or 
if the ether be turned on too quickly, the ordinary cough- 
ing and struggling would, of course, be produced. The 
apparatus, however, requires a little more attention to 
temperature and other details, and is rattier too compli- 
cated for general use. I have made several attempts to 
avoid the necessity of warming it. This can be effected 
by having the ether-vessel surrounded by a larger quan- 
tity of water at the ordinary temperature ; but then the size 
and weight of the inhaler become objectionable. Better 
success attended modifications of the instrument having 
the ether-vessel placed close against the face-piece, so as 
to receive more warmth from the patient's breath and 
from the hand of the administrator. 

"I am greatly indebted to Messrs. Mayer and Meltzer 
for their patience and ingenuity in carrying out my 
ideas, and my present object is to call attention to a 
portable regulating inhaler made by them. Its advan- 
tages are these : 1. It has no valves; 2. It supplies the 
vapor so gradual^ that patients breathe quietly ; 3. 



clover's ether inhaler. 39 

It produces sleep in two minutes; 4. It does not require 
fresh ether during the continuance of an operation ; 5. 
The recovery from a short operation is more speedy than 
with most Other inhalers; 6. It does not need to be 
warmed before it is used ; 7. No sponge or felt is re- 
quired; 8. Ether left in the inhaler can be saved for 
another time. 

"The face-piece is edged with an air-cushion. The 
ether-vessel and water-chamber rotate upon the mouth 
of the face-piece. When the instrument is first applied, 
the stopper should be towards the patient's forehead, 
and now he breathes in and out of the bag directly. As 
the ether- vessel is turned round, the air is obliged to en- 
ter the ether-chamber and pass through it before it 
reaches the bag ; and, when the vessel is turned half 
round, so that the stopper is opposite the patient's chin, 
all the air going in and out of the bag must pass through 
the ether-vessel. Two ounces of ether (specific gravity 
735) are enough for a long operation. Usually an ounce 
and a half is the proper charge. The opening for sup- 
plying the ether is arranged to prevent an excessive 
quantity being supplied ; but, to guard against the pos- 
sibility of a few drops escaping through the inner open- 
ings, there are two recesses made to catch them, and 
prevent the liquid ether from reaching the patient's lips. 

"The ether-vessel is spherical in shape, and one-half is 
surrounded b} r a closed water-compartment, to prevent 
the ether from becoming too cold. The bag need not be 
much distended when in use, and can be kept on one 
side so as not to obstruct the light in operations on the 
eye. The instrument is intended for giving ether with- 
out gas; but, by connecting the bag with a supply of 
nitrous oxide, it forms a tolerably efficient substitute for 
the gas and ether-inhaler above mentioned." 



40 ARTIFICIAL ANAESTHESIA. 



CHAPTER II. 

Sulphuric ether, not altogether free from danger, always gives nam- 
ing. What to doin case of alarming symptoms when employing ether 
as an anaesthetic. Use of air, artery forceps, artificial respiration in 
fainting, inversion of the body and head, application of stimulants, 
in c: se of blood, food or ether entering the trachea or bronchi. 
Statistics in reference to death from ether, I r. Andrews, of Chicago, 
Dr. Richardson, of London. Recent cases of reported deaths collected 
by the writer. Mr. Lawson Tait on the advantages of boiling anhy- 
drous ether. Examination of the Royal Medical Chirurgical Society, 
of London, into the comparative merits of ether and chloroform. 
Experiments with ether, with illustrations, by the sphygmograph, by 
the late Dr. Morgan, of Dublin, and his conclusions. Case of appa- 
rent failure of the heart's action, during the inhaling of ether, with 
recovery. Primary and secondary effects of ether. Reports of deaths 
from ether, by Drs. Holmes, A. Matthewson, 6. M. Lowe, Shreve, T. 
ft. Morton, and Saundly. Abstract of the report of the Boston Com- 
mittee on the alleged dangers from ether. Conclusions of the author 
in regard to ether. 

Sulphuric ether is not altogether free from danger, 
but it always gives warning before it causes the death 
of" the patient. The countenance should be watched and 
the difficulty in breathing promptly attended to the 
moment the face assumes a purple, dusky, or extremely 
pale hue. The first thing to he done is to remove the 
inhaling apparatus, and admit fresh air; if this is not 
sufficient, draw forward the tongue by means of a pair 
of artery forceps, or a napkin or handkerchief wrapped 
around it, also draw forward and support the jaw. If 
these means should fail to reestablish a healthy action 
of the lungs and cause due oxygenation of the blood, 
resort at once to artificial respiration, by means of Mar- 
shall Hall's method, or mouth of the physician to that 
of the patient, or by the use of a small pair of hand- 
bellow*, or air bag and nozzle having its valve on the side 
or base. 



SULPHURIC ETHER 41 

In the condition of depression or fainting, position — the 
inversion of the head and body — will be found of impor- 
tance, with careful administration of stimulants and 
nitrite of amyl to the patient's nostrils, using a tube 
with air bulb to force it into the lungs. Use heat by 
means of bottles of hot water or hot iron, wrapped in 
flannel and applied to the pit of stomach, frictions with 
mustard or pepper in hot water or oil of turpentine. If 
they should fail resort to a galvanic or faradic cur- 
rent; one pole to chest and the other to nape of the 
neck. If blood, food, or ether should have gotten into 
the trachea or bronchi, compression of the stomach and 
chest should be resorted to, also turn the head down- 
wards, drawing at the same time the tongue around, and 
keeping the mouth open. Expose the face and chest of 
the patient to pure air, but do not chill the body if 
moist, cold, or clammy. 

By combining the statistics collected in the United 
States by Dr. Andrews, of Chicago, and those of Eng- 
land by Dr. Richardson, of London, we obtain the mor- 
tality caused by ether (up to 1872), such as four deaths 
in 92,815, or one to 23,204. Since that period several 
more deaths have been reported (up to 1877) from ether 
in New York, Boston, Chicago, Philadelphia, and Eng- 
land. The fourth in Chicago, of which we have a published 
account; it being the first fatal result in an operation on 
the eye in this countiy. We republish this latter case, 
feeling almost sure that ether entered the trachea on ac- 
count of the use of the wet cone and sponge. "The 
patient being in the horizontal position, and in her 74th 
3'ear, having suffered from cough, had rales in her chest, 
etc. The details of the first operation have also been 
given; it having been successful under the ether, but 
giving such warning that the other eye should not have 
been operated upon at the time or under the same anaes- 
thetic." Dr. Holmes states:* "In the latter part of 
December the eyes were in so favorable a condition that 
I considered it safe to perform a preliminary iridectomy. 

* Death following the administration of ether at the Illinois 
Charitable Eye and Ear Infirmary, by E. L. Holmes, M.D., 
Chicago Medical Journal and Examiner, May, 1876. 

4* 



42 ARTIFICIAL ANESTHESIA. 

The patient took no food after breakfast. Sqnibb's 
ether (stronger) turned upon a large porous towel, folded 
several times and covered with paper, was given to the 
patient while lying on her back with her head slightly 
elevated. The patient breathed very quietly until she 
seemed to be unconscious, when coughing commenced. 
This was no more violent than is often observed when 
this anaesthetic is administered. Scarcely any mucus or 
saliva collected in the throat. Soon after this the breath- 
ing ceased, and the face became remarkabty livid, while 
the pulse continued regular and strong. Pressure on 
the chest aroused the respiration, when more ether was 
given, and the operation on each eye completed without 
further unpleasant symptoms. 

"There was no vomiting. The wounds in the corneal 
border healed readily, although, from a repeated recur- 
rence of slight conjunctivitis, I did not consider the eyes 
to be in a condition fit for the extraction of cataract for 
about three months. Meanwhile, the general health had 
continued as good in every respect as it had been. 

"Dr. T. N. Danforth had given the patient simple 
remedies to relieve a trifling cough and asthma, and to 
overcome the undue perspiration* 

" The asthma never prevented sleep in the recumbent 
position. 

"At half past three, on the twenty-seventh of March, 
Squihb's ether was again administered under precisely 
the same circumstances as at the previous operation. I 
must confess that nothing in the patient's condition ex- 
cited the least suspicion, either in Dr. Danforth or my- 
self, that a fatal result should follow. The thought 
never entered my mind, although I had some solicitude 
regarding the success of an extraction of cataract in an 
eye which might be considered predisposed to inflam- 
mation. 

" The patient was in a cheerful state of mind, and in- 
haled the ether quietly till about half a pound had been 
consumed, when quite violent coughing commenced. 

" This was soon followed by an extremely livid appear- 
ance of the face, and then by a cessation of breathing. 
I placed my finger on the pulse, found it failing in 
strength, and directed my assistant to remove the towel, 



SULPHURIC ETHER. 43 

and others in the room to raise the foot of the bed as 
high as possible. Meantime I raised the tongue, and, 
with the other hand, made very forcible pressure every 
few seconds on the side of the chest. Respiration was 
at once re-established, as also full action of the heart, 
when I directed the foot of the bed to be let down. The 
lividity in a great measure disappeared. Even at this 
moment I did not think of danger, but, without giving 
more ether, rapidly commenced and completed the sec- 
tion, and, as iridectomy had already been performed, as 
rapidly removed the lens. This passed through the 
wound at once with only the least possible manipulation. 
The bandage was speedil}' adjusted. I cannot think two 
minutes elapsed from the commencement of the section 
to the final adjustment of the bandage. 

"I made the steps as rapidly as was consistent with 
care, being not quite certain that the patient had taken 
ether enough to keep her unconscious sufficiently long 
for the possible delay in ' delivering' the lens, which 
occasionally happens. 

"My usual method of applying the compressive band- 
age reduces the time to a minimum, since I place an 
elastic band around the forehead, ready in any emer- 
gency to be slipped over the eyes. I am confident, there- 
fore, that all this required less than two minutes, when 
I observed that the patientdid not breathe, that the face 
was more livid and the pulse very weak. The same 
course was pursued as before the operation as regards 
drawing up the tongue, raising the foot of the bed, and 
inducing artificial respiration, and, in addition, by forc- 
ing air into the lung(?) by the breath. At the end of a 
minute or more I could feel no pulse nor hear the heart; 
the face had become exceed ingly livid. 

" The efforts I have described, except raising the foot 
of the bed, and forcing the breath into the mouth, were 
continued an hour and a quarter. 

"There were present my assistant, the matron, the 
resident pupil, and one of the nurses. Galvanism was 
not employed. No autopsy was obtained. 

"In neither case was the towel held so close to the 
face as to prevent the entrance of sufficient air into the 
lungs." 



44 ARTIFICIAL ANAESTHESIA. 

Mr. Lawson Tait* has stated that he had a case of 
severe bronchitis in an aged person following the admin- 
istration of ether, and lie therefore advises the adminis- 
tration of the vapor of boiling anhydrous ether, pure and 
free from any admixture of air. His apparatus con- 
sists of a reservoir, which holds about ten ounces of 
ether, free from water, furnished with a spring pump, 
which drives over into the glass boiler about a drachm 
of ether at each stroke. This boiler is suspended in a 
hot-water tank beneath which is a spirit lamp ; from the 
boiler there is an exit tube, four or five feet long, which 
passes to a "Junker's" mouth-piece. In the writer's ex- 
perience he has never known bronchitis to result from 
the inhalation of ether, except in persons who were 
already suffering at the time from some pulmonary diffi- 
culty. In a recent case in which the writer administered 
ether, by means of the inhaler, to a young person suffer- 
ing from a bronchial attack, with a most irritable cough, 
the patient was found to be better after the full influence 
of the anaesthetic than before its use. In the dyspnoea 
dependent upon chronic bronchitis Prof. G. B. Wood, of 
Philadelphia, considers the inhalation of ether doubly 
useful, if carefully managed, both by relieving the dis- 
tressing sensation and favoring mucous secretion. f 

Dr. W. Y. Gadberry,J of Yazoo City, Mississippi, re- 
cords some cases of capillary bronchitis treated effect- 
ually with inhalations of ether. 

A careful examination was conducted by the Royal 
Medical Chirurgical Society of London into the compara- 
tive merits of ether and chloroform, by means of the 
hemadynamometer in testing the effects on the heart's 
action and the influence of these agents upon it. The 
report states: " The essential difference between the ac- 
tion of chloroform and ether is to be found in the effect 
produced upon the heart. The first operation of both 
agents is to stimulate the heart and augmenf, the force 
of its contractions; but, after this, chloroform depresses 
the heart's action, whereas ether appears to exert but 
little influence upon the muscular movements of that 
organ." 

* The Practitioner, March, 1876, p. 206. 

t Wood's Therapeutics, second edition, vol. ii. p. 697. 

X Nashville Journal of Medicine and Surgery, Oct. 1866. 



SULPHURIC ETHER. 45 

The general accuracy of these experiments and re- 
sults, although tested by so comparatively coarse an 
instrument, is borne out by observations and experi- 
ments with the sphygmograph by the late Dr. Morgan,* 
of Dublin, who, with this delicate instrument, made 
numerous observations and experiments which are here 
given, and concludes, k ' I have taken all but one of 
these examples (eight cases) as the most unpropitious, 
occurring in patients of diminished health and vitality", 
3 r et it is evident that the most perfect anaesthesia 
could be invoked under the influence of ether, with an 
absolute stimulating effect on the circulation ; and that 
the condition of insensibility could be maintained for a 
considerable time, yet there was no material alteration 
of the 'pulse writing,' and the most perfect sense of se- 
curity was established. It i«, therefore, established 
that while chloroform exerts a depressing influence on 
the heart, ether exerts a stimulating one, and that chloro- 
form is the most dangerous." 



Fig. 8. 
Fig. 9. 



Fig. 8 represents the pulse of a female patient, aged 
twenty-five, who had been confined to bed for five 
months; pulse writing taken before etherization. 

Fig. 9 represents it during its full influence. It will 

* The Dangers of Chloroform and the Safety and Efficiency of 
Ether, etc., by J. Morgan, M.D., F.R.C.S., Professor of Surgical 
and Descriptive Anatomy, Royal College of Surgeons, Ireland, 
etc. London, 1872, p. 28. 




46 



ARTIFICIAL ANAESTHESIA, 

Fig. 10. 




be seen that the heart power indication was rather 
stronger during etherization than before. 

Another instance of a female, aged seventeen, also long 

Fig. 11. 




confined in bed. The contrast of Fig. No. 10, taken be- 
fore etherization, and of Fig. No. 11, during profound 
etherization, is notable ; the elevation of the pulse line 

Fig. 12. 




showing the stimulating property of the ethereal in- 
fluence. 

Fig. 12 represents the excited pulse writing of a small 

Fig. 13. 




and nervous female, previous to etherization and opera- 
tion. 

Fig. 13 represents the pulse writing of the same patient 



APPARENT FAILURE OF HEART'S ACTION. 47 

when steadied by etherization. The contrast is remark- 
ably favorable. 

Fig. 14 represents the pulse writing of a healthy young 
man, of twenty-two, previous to operation for artificial 

Fiff. 14. 




pupil ; an affection which had not interfered with his 
general health. 

Fig. 15 represents the same when taken under full 
etherization, and after the completion of the operation. 

Fig. 15. 




A comparison of this pulse writing with that of the natu- 
ral soft pulse, will be ample evidence of the safety of 
etherization in its action on the heart. 

Apparent Failure of Heart's Action during 
Inhalation of Ether. 

This interesting case is reported by Mr. Morton, M.B.,* 
senior house-surgeon Royal London Ophthalmic Hos- 
pital. " George S., shipwright, aged forty-four, a strong, 
healthy-looking man, came to the hospital on the 25th 
Sept. 1876, with his left eye lost by an injury sustained 
some time since. He consented to have the eyeball re- 
moved, for which purpose anhydrous ether, as prepared 
by Messrs. Robbins & Co. for general anaesthesia, was 
administered by Mr. Morton, after the method always 
employed at this hospital, namely, a conical sponge hol- 
lowed in the middle, and lined with flannel. There was 

* London Lancet, January, 1877, Am. ed. p. 12. 



48 ARTIFICIAL ANAESTHESIA. 

not nearly so much struggling as there is frequently, 
though there was some unwillingness to respire freely, 
and a tendenc}' to dropping of the lower jaw, with a fall- 
ing back of the tongue; but by forcibly holding forwards 
the lower jaw by means of his beard, the patient was 
fully anaesthetized in about seven minutes, after inhaling 
about five ounces of ether. All went well to the comple- 
tion of the excision, when, having removed the inhaler, 
though still holding forward the man's lower jaw, Mr. 
Morton was proceeding to compress the bleeding tissues 
when he observed that there was no hemorrhage. The 
man's lips were then noticed to be very pale, as was also 
his whole face; and his respiration had ceased. Artificial 
respiration was at once commenced, and one of the assist- 
ants, who was raising and lowering the arms, felt that 
the pulse was extremely feeble. The tongue was also 
forcibly drawn forwards, as it had fallen far back in the 
mouth, although the lower jaw was being held forwards. 

41 After the artificial respiration had been continued 
some eight or ten minutes the patient made one or two 
feeble efforts to breathe, and the conjunctivae were be- 
coming sensitive, when one of the clinical assistants 
suggested the use of nitrite of amyl, four minims of 
which were accordingly given on a piece of lint, and 
artificial respiration continued ; but the patient soon 
began to breathe for himself, and speedily recovered 
consciousness, walking out of the theatre a few minutes 
afterwards. 

"This case, according to Mr. Morton's impression, seems 
to have been one of cardiac failure, as indicated by the 
pallor of the face and lips and the feebleness of the pulse, 
though it may be thought by some to have been due to 
an obstruction to the respiration from his tongue having 
fallen back. This is scarcely likely, for he had breathed 
to within a very few seconds of the time that the absence 
of respiration and the extreme pallor were noticed. 
Further, Mr. Morton remarks that in all cases, now more 
than 500, in which he has administered ether, if there 
has been any obstruction to the respiration it has always 
been accompanied by intense congestion of the face and 
blueness of the lips; yet in some cases, where vomiting 
is about to occur, this is preceded by pallor and profuse 



SECONDARY RESULTS OF USE OP ETHER. 49 

sweating, but that does not apply to the present case, 
for there was no vomiting, nor any tendency to it. It 
would be interesting to know whether others have seen 
cases in which there has been cardiac failure during the 
inhalation of ether, and it is important to note the fact 
that holding forward the lower jaw did not prevent the 
tongue falling back, as it is commonly alleged to do. In 
conclusion, it may be stated, that the patient has a slight 
mitral regurgitant murmur, and occasionally suffers from 
difficulty in breathing, after a hard da3 7 's work." 

Secondary Results of the Use of Ether. 

Death under the care of Dr. A. 3fatthewson, of Brook- 
lyn* — "The ether was taken rapidly (time not given). 
The operation of iridectomy was performed, and recovery 
so far advanced (not complete) that the patient was left 
with an attendant (not a medical man). A quarter of an 
hour later the house surgeon was called, and told that, 
after some efforts to vomit, the patient had a fit (either 
from food in the larynx or tiie falling back of the tongue, 
causing asph} r xia, followed by convulsions), and so the 
patient died. 

"At the autopsy a large hemorrhage was found under 
the arachnoid, on the upper surface of the left hemi- 
sphere. The vessels on the side were full, and there were 
numerous capilliform extravasations. There was a large 
clot in the right ventricle, a smaller one in the left ; the 
corpus striatum and optic thalamus were softened and 
broken down, and the vessels of the base of the brain 
were atheromatous." 

* Boston Medical and Surgical Journal, Oct. 1876. 
6 



50 ARTIFICIAL ANESTHESIA. 



Primary Results following Death from Inhala- 
tion of Ether. 

" We regret to have to record a case in which the ad- 
ministration of ether terminated fatally, and which 
occurred in the practice of Dr. G. M. Lowe, of Lincoln. 
The patient was a lady forty-eight years of age, who 
had discharged the duties of a governess in the family 
of Dr. Lowe, and had for some time past been suffering 
from cancer of the breast. A consultation was held, and 
the removal of the tumor determined upon. The ad- 
ministration of the ether was confided to Dr. Mitchinson, 
who had large experience in its employment. All pro- 
per precautions appear to have been taken. Dr. Mitch- 
inson examined the heart, and, finding it rather feeble, 
directed the patient to take a little brandy and water. 
She was quite cheerful, though somewhat nervous. Half 
an ounce of ether was poured on the inhaler, which was 
placed over the mouth in the usual way. The valves 
were open, and gave free ingress and egress to the air. 
After a few inhalations the patient's face suddenly be- 
came turgid and the hands white. The inhaler was at 
once removed, the tongue brought forward, cold water 
dashed over the face, and the chest rubbed with brandy; 
but the breathing became stertorous, the face more and 
more congested, the pulse failed, there was an effort at 
vomiting, and death took place within a few seconds. 
A post-mortem was made by Mr. T. Sympson, the Senior 
Surgeon of the Lincoln County Hospital, assisted by 
Mr. T. Brook. On examining the heart, they found that 
it was feeble and flabby, and some of the tissue, being 
afterwards examined, was found to have undergone fatty 
degeneration. The liver was firm, but the whole of its 
upper surface was attached by old adhesions to the under 
surface of the diaphragm — the muscular partition be- 
tween the chest and the abdomen. There was a little 
effusion of serum on the brain. The air-cells of the 
lungs were dilated. The valves of the heart were in a 
perfectly healthy condition. They also carefully ex- 
amined the throat, and found nothing there to throw 
light on the cause of death. The stomach was perfectly 



DEATH PROM INHALATION OF ETHER. 51 

healthy ; the deceased had not partaken of an}' food for 
some time before the ether was administered, which is a 
point of great importance. Mr. Sympson attributed the 
fatal result to failure of the heart's action, and the im- 
pairment of the functions of the diaphragm iri conse- 
quence of its attachment to the liver. The fibres of the 
heart were so feeble as to be unable to bear an} r extra 
strain, and the efforts at resuscitation proved abortive, 
owing to the failure of the functions of the diaphragm. 
Mr. Brook's evidence was to the same effect. They 
noted, in addition, that the right side of the heart was 
gorged with blood, that the walls of the right ventricle 
were very thin, and that there were some nodules of can- 
cer in the liver and lungs."* 

" Some cases in which ether has been followed by 
alarming symptoms have lately been recorded. They 
have been termed syncope, but the word is not appro- 
priate, as the heart continued to beat after respiration 
ceased. This is what should have been anticipated. 
When death is produced by ether, the animal's heart 
continues to beat long after the arrest of respiration. 
The pulse is quickened by ether, and maintains its force 
through a long state of anasthesia. In these facts lies 
the safety of ether. But it should never be forgotten 
that there is danger at a certain stage, and the clanger 
is from the side of the respiration, which at length 
ceases. 

"Stertorous breathing proceeds from paresis of the 
muscles of the palate, and should lead to the ether being 
suspended. So respiration, growing more and more 
shallow and less frequent, is a warning, and should not 
be overlooked. It is very rare that the heart fails — per- 
haps never. Pallor is rare, too, and should excite atten- 
tion if it occurs. But, we repeat, the danger of ether 
is from the side of respiration, that of chloroform from 
the heart, and this fact goes far to explain their relative 
safety. In chloroform narcosis the danger is much more 
sudden. Ether gives warning."f 

* Lancet, Nov. 17. t The Doctor, London. 



52 ARTIFICIAL ANESTHESIA. 



Fatal and Dangerous Effects from Ether. 

The following cases are given in the " Practitioner," 
August, 1877, by Dr. Shreve: — 

" Case 1. — Was seen in consultation. The patient was 
a 3 r oung man, sixteen years of age, of dark complexion, 
and of good muscular development. His previous habits 
good, and also his general health. One month previously 
he had received a pistol-shot wound. The bullet entered 
just above the knee, and emerged on the posterior part 
of the limb, just below the popliteal space. His condi- 
tion when seen was that of anaemia, consequent on loss of 
blood at the time of the injury, and the pain and inflam- 
mation that succeeded. The pulse was regular and weak, 
the face was extremely pale, and respiration regular; he 
complained of pain in the region of the knee, which was 
very much swollen and tense. Ether was administered, 
and he passed under its influence very pleasant^ ; there 
was no excited period during its inhalation. An incision 
was made into the most dependent part of the swelling, 
and a large quantity of old clots escaped. This was fol- 
lowed by quite a smart hemorrhage from the direction 
of the popliteal artery. The hemorrhage was controlled 
by the immediate application of pressure. The respira- 
tion, which up to this time had been perfectly regular 
and quiet in its character, suddenly stopped. He had 
inhaled on\y three ounces of ether, and the sponge had 
been removed from- his nose for a minute or two. The 
face and lips were extreme^ pale, and arrest of respira- 
tion took place with such insidiousness that it seemed as 
if the patient had suddenly omitted a breath. The pulse 
was regular and feeble at the wrist, and for a moment 
it seemed like the slight arrest of respiration seen in the 
administration of ether, where a shake arouses the 
patient, and he makes a deep inspiration, and goes on 
breathing regularly. Artificial respiration was resorted 
to, ammonia injected hypodermically, stimulating enema 
administered; all without avail, as the patient never 
breathed again, although the pulse continued perceptible 
at the wrist for some time after the stoppage of the 
respiration." 



FATAL AND DANGEROUS EFFECTS FROM ETHER. 53 

Remarks on the first case: — Here there was sufficient 
cause of death without the ether; there was evidently air 
admitted into the circulation, or death occurred from loss 
of the small quantity of blood remaining in the system, 
or the sudden formation of a heart clot. No stimulant 
was given before this severe operation upon an 
anaemic subject, nor is it stated in what position he was 
in, which was surely indicated by his feeble pulse. No 
post-mortem was made, which increased the uncertainty 
of the case. 

"Case 2. — Was a case of abortion, in a lady aged about 
forty, married, and of dark complexion. She was fleshy 
and sallow, and had been flowing forty-eight hours when 
I was called to see her, in consultation. Ether was ad- 
ministered to relieve the pain of removing the placenta, 
as the uterus was situated high up in the pelvis. The 
pulse before the operation was moderately strong and 
slightly accelerated. The patient passed under the 
effects of the anaesthetic without a struggle. The pla- 
centa was removed in pieces, it being adherent to the 
walls of the uterus; its removal was accompanied by no 
undue amount of hemorrhage, and the etherization was 
discontinued. Having examined the pulse, and found it 
somewhat fuller than before the operation, and the respi- 
ration regular, I left the attending physician in care of 
the patient, and went to another part of the room to 
wash my hands, where I was joined by the doctor, and 
while engaged in conversation with him, and the same 
time looking at the patient, her respiration sudden^ 
ceased. Our efforts for her relief were directed entirely 
to artificial respiration. After about two minutes she 
began to respire ngain, at first feebly and at intervals, 
but soon after with strength and regularity. The pulse 
was regular and weak at the wrist during the whole 
period of stoppage of the respiration." 

Remarks on the second case. — Here again the etheriza- 
tion had ceased, and the gentleman had left the patient 
all right, and we feel satisfied the ether had little or 
nothing to do with this feeling of fainting, which is 
almost certain to follow a detached placenta. It is 
always proper to administer under such circumstances 

5* 



54 ARTIFICIAL ANESTHESIA. 

some stimulant, either brandy or whiske\ r , with some 
preparation of ergot. We have frequently had the pulse 
to cease almost at the wrist, and no apparent respiratory 
movement, from filling up of the uterus with a soft clot, 
when rough handling of the patient or kneading of the 
uterus will cause expulsion of the clots, and with it re- 
lief to all the symptoms. The italics are ours in each 
of the cases. 

" Case 3. — Was seen in consultation. The patient was 
a lady of about forty years of age, married, and had had 
several children. She had been ill wilh monorrhagia 
for eleven years, and presented a degree of anaemia that 
was most ghastly. Her complexion was perfectly waxy, 
and almost transparent in its whiteness. On digital ex- 
amination of the vagina the cervix admitted the tip of 
the index finger, and was full of granulations. A sponge- 
tent was introduced, and left until the next day, when 
it was decided to etherize sufficiently to relieve the pain 
of the examination of the uterine cavit}'. The imme- 
diate effects of the etherization was all that could be 
wished. The whole lining membrane of the uterus, like 
the cervix, was lined with granulations and fungosities. 
"While the attending physician was confirming my diag- 
nosis the respiration suddenly ceased. The head, which 
had been low, was placed still lower, and artificial respi- 
ration was immediately resorted to. After persistent 
efforts for about three minutes, that seemed an eternity, 
I discovered a slight superficial respiration, which we 
continued to supplement and assist until respiration be- 
came normal. The pulse remained about what it was 
before the etherization, both as to its regularity and 
strength, during this whole period. I might add that 
the action of the sponge-tent proved entirely remedial, 
although originally used only as a means of diagnosis." 

Secondary Results of the Use of Ether.* 

" David D. P., aged nineteen, single, a telegraphic ope- 
rator, consulted me in May, 1876, in regard to his right 

* Am. Jour. Med. Sciences. " Details of a case in which death 
is supposed to have resulted from ether used as an anaesthetic; 



SECONDARY RESULTS OF USE OP ETHER. 55 

limb, which was quite useless from general atrophy, and 
an angular partial anchylosis of the knee, evidently a 
result of old scrofulous inflammation. I advised divi- 
sion of the flexor hamstring tendons, which were very 
much contracted, and immediate straightening of the 
limb, and directed an appropriate brace to be made, with 
a high heel and sole to the shoe for after-use. On the 2d 
of June the patient was admitted into the hospital, when 
the following notes were made by Dr. W. B. Hopkins, 
the resident in charge: 'Until the patient was two 
years old, when he began to walk, he had been considered 
a perfectly health} 7 child ; soon after this a posterior spi- 
nal curvature developed ; when four years old, inflamma- 
tion of the knee set in, with subsequent contraction of 
the flexor thigh muscles, with general arrest of develop- 
ment in the limb, and subsequent partial anchylosis of 
the knee-joint, the angle of deformity being slightly ob- 
tuse ; there had been apparently no suppuration of the 
joint, at least to the extent of an abscess.' 

M The spinal and limb troubles combined prevented 
the patient from walking until he was six years old, when, 
with crutches, he began to get about; there is no history 
of winter cough or previous chest trouble, and his gen- 
eral health, although not being vigorous, seems not to 
have been markedly impaired, and no evidence of any 
hereditary disease can be traced out. The patient is 
rather pale, but his appetite is good, and he expresses 
himself as in excellent health ; there is marked posterior 
curvature, which has produced the usual deformit} 7 , with 
great sternal prominence. The right limb is much 
atrophied and shortened, and presents angular deform- 
ity, with a partial luxation backward of the tibia, the 
anchylosis not being complete. June 3d, after a consul- 
tation with Drs. Hewson and Hunt, the tendons were 
divided, and the limb was straightened, and the appara- 
tus, made especially for the case, was adjusted by Mr. 
Kolbe. 

"The etherization was conducted by Dr. Wharton, one 

with a Brief Account of all the Fatal Results which have been as- 
cribed to the use of Anaesthetics at the Pennsylvania Hospital ; 
with remarks." By Thomas G. Morton, M.D., Surgeon to the 
Pennsylvania Hospital. 



56 ARTIFICIAL ANESTHESIA. 

of the resident physicians; at the close of the operation 
I saw that the patient was pale, somewhat depressed, 
but as comfortable apparently as we generally observe 
after the use of an anaesthetic. The patient was left in 
charge of Dr. Hopkins, whose subsequent notes are as 
follows: 'At 12.30 P. M., patient, having been removed 
fifteen minutes ago to his room, was seized with symp- 
toms of asphyxia; pulse moderately full, 160; respira- 
tions nearly ceased ; general cyanotic condition more 
marked in the face and tips of the fingers ; his tongue 
was at once depressed, cold water dashed on his chest, 
which produced only violent respiratory efforts. At 1 
P. M. condition remains much about the same, and there 
being evidences of pulmonary engorgement, with frothy 
blood-stained mucus constantly collecting in the throat, 
while the heart's action was active and labored, the 
radial artery was opened, and about eight ounces of 
blood were drawn ; dry cups were applied to the chest; 
for a time the respiration seemed slightly improved ; the 
volume of the pulse increased somewhat, and fell from 
160 to 152 per minute. At 1.45 rapidly sinking; li3 r po- 
dermics of whiskey and carbonate of ammonia were used 
without avail.' Dr. H. sent me the following note: i P. 
died at 2 P. M. ; about ten minutes after the operation 
he was removed to his room, being perfectly conscious, 
and I having seen to it that he had perfectly recovered 
from the ether, he suddenly became asphyxiated ; the 
ordinary remedies proved of no avail.' 

"Dr. Morris Longstreth, the hospital pathologist, 
made the post-mortem twenty-one hours after death. 
4 The rigor mortis was well marked ; there was consider- 
able deformity of the chest ; the lumbar portion of the 
spinal column was at its lower part bowed backwards, 
so that the last two vertebrae were nearly in a right line 
with the upper portion of the sacrum, thereby making 
the cavit}- of the pelvis very capacious. The abdominal 
viscera were normal, although somewhat out of position. 
Thorax — the pleural cavities contained a considerable 
amount of serum, included in the meshes of an abun- 
dant firm network of inflammatory adhesions (old). The 
serum contained no recent lymph, and it was impossible 
to determine its quantity, on account of the very great 



SECONDARY RESULTS OF USE OF ETHER. 57 

amount of similar serum pressed out from the lungs in 
the process of their removal ; the lower part of the right 
pleural cavity was, to a considerable extent, obliterated 
by very firm adhesions existing between the diaphragm 
and the costal pleura. The amount of serum was not 
very great at any one portion of the pleural sac, but 
rather diffusely infiltrating the adhesions present. Both 
lungs were moderately well crepitant throughout, pitted 
deeply on pressure everywhere ; on section, serum, frothy 
and a little bloody, exuded with great freedom and in 
large amount, as though from a saturated sponge ; their 
cut surface was grayish, showing some blood points; 
there was no solidification or even deep congestion of 
their tissues. Divided portions, as well as the whole, 
floated well in water, and there was no evidence of plug- 
ging of their vessels, and the blood in them was entirely 
fluid. Pericardium contained a considerable amount of 
clear, very pale serum ; the heart was only moderately 
in a state of muscular contraction, a slight amount of 
fat covered its surface along the grooves ; the blood 
within the cavities was quite fluid ; the muscular tissue, 
the valves, aud the large vessels were all normal. There 
was no foreign substance of solid nature discovered in 
the larger bronchi or in the trachea. The other parts of 
the body were not examined.' 

" The unfortunate result in this case, apparently 
caused by ether, naturall}' produced, not only upon my- 
self, but upon those who had a knowledge of it, a pro- 
found impression, as it was seemingly a proper one for 
the use of the anaesthetic. Ether or 4 washed ether' as 
an anaesthetic agent has been uniformly looked upon as 
perfectly safe; personally, I have administered it on all 
occasions, at all periods of life, from infancy to extreme 
old age, with the feeble as well as in the strong. In 
giving ether I have never used any l inhaler,' so called, 
but have invariably made use of a napkin or coarse 
towel, on which the ether is poured, when the cloth is 
then simply folded in a conical shape, and held over the 
patient's mouth and nose ; so soon as the napkin be- 
comes the least soiled or 'ether-logged,' a fresh one is 
substituted. Dr. Wharton, the resident who gave the 
ether in this case, says : ' I am satisfied that not over 



58 ARTIFICIAL ANESTHESIA. 

two and a half or three ounces were administered in P.'s 
case ; he seemed to be readily affected, and was not under 
its influence over twenty minutes. There was no vomit- 
ing, and the respirations were not labored ; on removal 
of the napkin he rapidly regained consciousness.' Al- 
though this patient had a marked spinal curvature, with 
chest capacity below the average, anaesthesia on this ac- 
count was not contraindicated, for I have frequently 
used ether in cases where the deformity of the chest was 
much more marked without the least difficulty. The 
autopsy demonstrated that the lungs were seriously re- 
stricted in their natural movements by the adhesions 
which bound them down in all directions, and conse- 
quently the secretions which formed were not expelled ; 
at the close of the etherization there was no evidence of 
any mucous collection, at least when I last saw the pa- 
tient at 12 M.; fifteen minutes later, when Dr. Hopkins 
was called, the change was very marked, and it was dur- 
ing this short interval that the serious symptoms were 
manifested. Mucous secretion, which often rapidly 
forms, is one of the most annoying symptoms in the 
course of etherization ; in many cases it is not observed 
at all, but when it occurs to any extent, it is much safer 
to suspend anaesthesia until the throat is thoroughly 
cleansed, or the patient is relieved by his own efforts. I 
have often observed that those patiejits who have been 
the most difficult to manage while being etherized, are 
the easiest to keep anaesthetized after the first excite- 
ment of the ether has passed over, and seldom suffer 
from an}' mucous secretions. Gross (Surgery, vol. i., 
569, 5th ed.), when on the subject of death from ether, 
says: 'How the inhalation of ether proves fatal has 
not been decided; when death occurs promptly, as dur- 
ing, or very soon after, the administration, the proba- 
bility is that it is caused by asphyxia, whereas, when it 
occurs at a later period, as after the lapse of hours or 
days, there is reason to believe that it is due to the 
effects of congestion of the brain and lungs, either alone, 
or in conjunction with gastric irritabilit} T , which often 
exists in a most distressing degree.' 

M In P.'s case death was the result of the mucous secre- 



SECONDARY RESULTS OF USE OF ETHER. 59 

tion and serous effusion which invaded every available 
space, thus suffocating the patient; there was not the 
least evidence of any intra-cranial difficulty; the patient 
was quite rational to the close. 

" There is seldom any danger from ether when pro- 
perly administered, and there is abundant evidence to 
show that fatal results are less likely to follow its use 
than any other anaesthetic agent. The fact of ether hav- 
ing uniformly been looked upon as a per fectty safe agent 
on every occasion ma} T , I am inclined to think, have in- 
duced great carelessness in its use; the occasional deaths 
from or at all associated with ether should in the future 
be sufficient to serve as cautionary signals, a constant 
watchfulness should be observed by the etherizer, and 
every symptom carefully noted, especially all complica- 
tions arising from bronchial secretion, pulse failure, or 
vomiting, and I am satisfied that not only should the 
patient be watched b}' a medical man during anaesthesia, 
but until reaction has been thoroughly established, and 
the ether effects entirely passed over ; I have seen, as 
probably all surgeons have, ether poured upon the inhaler 
or napkin in great excess, so as to flow down on the pa- 
tient's face and neck; the cloth thus becomes saturated, 
is not pervious to air, and the patient almost suffocates; 
such practice cannot but be severely condemned. 

" The assistant should devote his attention exclusively 
to the patient, while a few drachms at a time, with care, 
poured on the napkin will generally induce anaesthesia 
promptly ; when the napkin becomes the least soiled, an- 
other should be substituted, and when complete anaes- 
thesia has been induced, occasional inspirations of pure 
air should be allowed. Ether has been most successfully 
employed in the Pennsylvania Hospital for more than 
twenty-five years; it was introduced about 1850, and first 
used in a case of luxation of the femur, which resisted 
repeated attempts at reduction with the pulleys; it is 
needless to say that after etherization no diffiulty was 
experienced, and from that time to the present this agent 
has been in daily use, and with the few exceptions herein 
noted has been the only anaesthetic emploj'ed." — American 
Journal of the Medical Sciences, October. 



60 ARTIFICIAL ANAESTHESIA. 

A death from ether has been latety recorded. Mr. 
Robert Saundly, of Birmingham, gives the following 
typical instance in the London Medical Press and Cir- 
cular: " M. C, aged 35, was admitted for contracted 
knees. On October 4th, at 12.45 P.M., I administered 
ether with Ormsby's apparatus; it appeared to me a very 
favorable case ; very little of the anaesthetic was used ; 
there were no alarming incidents; very little stertor or 
cyanosis; no vomiting; no obstruction to respiration, 
which was throughout regular and full. After Mr. Bart- 
left had straightened the limbs, some time was consumed 
in adjusting splints, during which time no ether was 
given ; and, as there appeared to be absolutely nothing 
to call for any notice at the time, I watched her with the 
utmost satisfaction, and allowed her to be carried out of 
the theatre without arousing her from the sleep into 
which she had fallen. She was removed on a stretcher, 
and was well wrapped up, but, to reach her ward, was 
carried about fifty yards across to the open court, the day 
being fine. After being placed in bed, she roused and 
spoke to the nurse, who noticed nothing unusual about 
her. At 2.45, about one hour and a half after her return 
to the ward, she became suddenly alarmingly ill, and 
when seen by the house physician (in the absence of the 
house surgeon) she was cyanotic and pulseless, with rales 
all over the thorax. All attempts to rally her were fruit- 
less, and she died at 4.15 the same afternoon. 

" The post-mortem examination made the following 
day showed some oedema of the membranes of the brain ; 
no thrombosis of the pulmonary artery; heart healthy, 
containing little blood in the right auricle ; ventricles 
contracted; lungs pale and cedematous ; other organs 
healtl^. 

" There seems to be no doubt that the deceased com- 
pletely recovered from the ether narcosis, but died from 
oedema of the lungs, which supervened one hour and a 
half after her removal from the theatre." 



SULPHURIC ETHER. 61 

Alleged Dangers which accompany the Inhala- 
tion of the Vapor of Sulphuric Ether.* 

Had we space, we should be very glad to copy the 
whole of this able pamphlet, but we must be content to 
give the conclusions which accompany it. We had before 
receiving it copied from Dr. Taylor on Poisons all the 
cases reported by 'him ; but we found, on carefully read- 
ing it, that his cases were included in the appendix to the 
report of the Boston Society. In justification of the con- 
clusions arrived at by the committee there are presented 
in this report forty-one cases gathered from every avail- 
able source up to the year 1861, the date of publication. 

u The general conclusions which have been arrived at 
by 3'our committee may be summed up as follows: — 

" 1st. The ultimate effects of all anaesthetics show that 
they are depressing agents. This is indicated both by 
their symptoms and by the results of experiments. No 
anaesthetic should, therefore, be used carelessly, nor can 
it be administered without risk by an incompetent person. 

" 2d. It is now widely conceded, both in this country 
and in Europe, that sulphuric ether is safer than any 
other anaesthetic, and this conviction is gradually gaining 
ground. 

" 3d. Proper precautions being taken, sulphuric ether 
will produce entire insensibility in all cases, and no anaes- 
thetic requires so few precautions in its use. 

u 4th. There is no recorded case of death, known to the 
committee, attributed to sulphuric ether, which cannot 
be explained on some other ground equally plausible, or 
in which, if it were possible to repeat the experiment, 
insensibility could not have been produced and death, 
avoided. This cannot be said of chloroform. 

" 5th. In view of all these facts, the use of ether in 
armies, to the extent which its bulk will permit, ought to 
be obligatory, at least in a moral point of view. 

" 6th. The advantages of chloroform are exclusively 

* Eeport of a Committee of the Boston Society for Medical Im- 
provement on the Alleged Dangers which accompany the Inha- 
lation of Sulphuric Ether, pp. 36. Boston : David Clapp, 334 
Washington Street. 1861. 
6 



bZ ARTIFICIAL AN/ESTHESIA. 

those of convenience. Its dangers are not averted by its 
admixture with sulphuric ether in any proportions. The 
combination of these two agents cannot be too strongly 
denounced as a treacherous and dangerous compound. 
Chloric ether, being a solution of chloroform in alcohol, 
merits the same condemnation." 

Inflammability of Ether. 

Two accidents have come to our knowledge in which 
the ether was ignited, and, although causing no actual 
injury, produced much fear and confusion. The first was 
where a bottleof ether was accidentally broken and ignited 
while Dr. Win. Hunt was operating, during the night, at 
the Pennsylvania Hospital. The second occurred while 
Dr. Win. H. Pancoast was applying the actual cautery 
to a patient at the Jefferson College Hospital clinic dur- 
ing the day. Dr. Bigelow, of Boston,* in commenting 
upon the inflammability of the vapor of ether, observes, 
u Its practical safety is doubtless partly owing to the 
fact that the air, cooled by its evaporation, establishes a 
downward current,f so that a match placed a few inches 
above an ether sponge at the edge of a table will not 
ignite it; while below, the vapor readily takes fire." It 
would, therefore, be much safer, when operating at 
night with ether, to have the flame of the lamp covered 
with a shade, and have the light always placed several 
inches above the ether. 

General Conclusions. 

The great safety of this anaesthetic agent depends 
upon the warning which it always gives in regard to its 
influence upon the life of the patient. The number of 
cases of death from its direct effects have been very few 
compared with the immense number of cases of pro- 
longed application. It will also be noticed that, in 
our cit}', where ether has been employed from the first 
discovery of its valuable qualities, the only death re- 

* Boston Medical and Surgical Journal. 

t This is duo to the greater density of ether vapor, for whilst 
the ether itself has a sp. gr. of .728, its vapor has 2.568 lor its 
sj>. gr., and this fact may he readily noted by ohserving the down- 
ward currents of vapor when pouring from one bottle to another. 



GENERAL CONCLUSIONS. 63 

ported has been from its secondary effects upon the 
lungs of the patient (see Morton's case), and some time 
after the case had been removed from the operatiug 
room to the ward, and, as I am now convinced, from a 
reduction of temperature of the skin, causing congestion 
of the lungs and brain, the avoidance of which w r ill 
prevent such results. 1 have not failed to collect from 
every source within my reach every case of injury or 
death which has been ascribed to ether. That ether is 
not entirely free from danger, in the hands of careless 
or incompetent persons, no one w r ould dare or attempt 
to den}', for we at times find the most simple article of 
the materia medica, when improperly employed, become 
a fatal agent. Ether has proven by experience to be the 
safest anaesthetic agent that has yet been discovered, 
with the exception of nitrous oxide gas, and this latter, 
from its naturally restricted character, cannot be era- 
ployed in all operations. According to Dr. H. M. Jones,* 
u within the last three or four years the advantages of 
ether over chloroform or methylene have been forced 
on the notice of the profession in the United Kingdom, 
and it has been adopted exclusively in some and par- 
tially in many of the large hospitals." This is strong 
evidence in its favor from a source for which we must all 
have a very high respect. The surgeons of Great Britian 
had a natural pride in employing chloroform, its prac- 
tical usefulness as an anaesthetic having been discovered 
and applied in that country. Still they were forced by 
medical public opinion to these very conclusions from 
the constantly recurring deaths from chloroform. This 
condition of things was well expressed by the editor, 
Dr. Hart, of the British Medical Journal. u Collecting," 
he saj T s, " from every source, information as to the ad- 
ministration of ether as an anaesthetic, we have invited 
from all quarters comment and communication, calcu- 
lated to completely inform the professional mind. The 
papers by Clover, Haj'ward, Norton, Bowditch, Fifield, 
Hutchinson, the late John Murray, and a host of others, 
appeared to us to establish, the superior safety of ether 

* See Dr. Jones's valuable pamphlet on the Medical Responsi- 
bility in the Choice of Anaesthetics, pp. 37. H. K. Lewis, London, 
1876, 3. 



64 ARTIFICIAL ANESTHESIA. 

over chloroform, and this led to a very large and general 
substitution of ether for chloroform as a surgical anaes- 
thetic." 

There are a few cases in which ether should not be 
employed as an anaesthetic ; these we shall endeavor to 
enumerate. The first class is in very aged persons with 
emphysema, hypertrophy of the heart, fatty heart, or 
valvular lesion. The second class are those who are 
known to faint from very slight causes. The third class 
are habitual drunkards, or persons who drink in small 
quantities frequently each da}'. The fourth class is 
from limited action of the lungs from old pleurisj', or 
pneumonia or irritation of the mucous membrane with 
excessive secretion. 

In anaesthesia by ether the real danger to be avoided 
is over-inebriation. It may be divided into three stages. 

First stage, of exhilaration ; second stage, that of 
stupor with snoring, or complete insensibility, which, 
with care, can be gradually increased or diminished with 
safety; third, dangerous state, that of coma with stertor, 
or the patient becomes livid with true asphyxia, or may 
alternate between livid i t v, with a falling pulse, with 
apparently alarming indications. 

There are a certain class of patients that pass into an 
almost profound state of unconsciousness without these 
distinct stages, while others require two or three assist- 
ants to hold them while inhaling, and have a wild excited 
stage, then pass, after a longer or shorter time, into the 
stage of stupor; these latter are termed by those who are 
familiar with the administration of amesthetics "bad 
etherizers," and here comes the importance of experi- 
ence. Indeed, no one should he trusted with the inha- 
lation unless he has passed through a course of in- 
struction ; for, unless great discretion is shown in giving 
or withdrawing the agent, the result may be fatal, 
while, with proper care, even in these bad cases, you 
may ultimately reach a stage of stupefaction, and all go 
well. The following case illustrates another class: — 

Oct. 4, 1817, Jefferson College Hospital. In a case of 
mastoid disease, in which I perforated the bone and 
opened the cells, m} r friend, Dr. Allis, administered the 
ether, the patient made but little effort at respi ration, 



MIXTURE OF ETHER AND CHLOROFORM. 65 

and, after consuming from six to eight ounces of ether 
for a full half hour without producing the true anaesthe- 
tic result, he had to resort to the use of chloroform, pure 
and alone. This is not the first case in which, in the 
hands of even the most careful administrators, the ether 
has not produced the result desired, and we are under 
the necessity of resorting to the use of the more dan- 
gerous agent, but this must not be done until a full and 
free trial of the milder and safer agent, always in care- 
ful hands, and only in the most important and very 
painful operations. 



CHAPTER III. 

Mixtures of ether and chloroform ; Dr. Washington L. Atlee. Death of a 
lady in Boston under Dr. Easthani, a dental surgeon of that city. 
Coroner's jury under charge of Dr. Ainsworth. Autopsy by Dr. Fitz, 
pathologist to the Massachusetts General Hospital. Methylic ether, 
its safety and best method of employment, by Dr. B. W. Richard- 
son, of London; Dr. Carter's opinion, also Dr. Jones, of Cork. Use of 
bichloride of methylene, by Dr. Spencer Wells, at Samaritan Free 
Hospital,- his doubts about its composition. Dr. Taylor's statement 
that it is a mixture. Report of five cases of death from this com- 
pound. Amylen ; introduction and use by Dr. Snow. Bromide of 
ethyl or hydrobromic ether, chemical composition and properties ; 
experiments with frogs, rabbits, dogs, etc., by "Rabuleau." Mode 
of preparation. Experiments of the writer on frogs and man. Its 
use in the ear, etc. 

A mixture of two parts of ether with one of chloro- 
form has been employed with success by so careful an 
operator as Dr. Washington L. Atlee. 

I have had the charge of the anaesthetic mixture (one 
part by measure of chloroform and two of washed sul- 
phuric ether) in an operation by Dr. Washington L. 
Atlee, during the successful removal of an ovarian tu- 
mor weighing forty pounds, and have also assisted him 
in three cases in which others gave this same mixture, 

6* 



66 ARTIFICIAL ANESTHESIA. 

with good results, and with no apparent risk to the 
safety of the patients. 

Dr. Atlee always administers the anaesthetic after the 
patient is upon the operating table, and one individual 
has charge of and is responsible for it. In his three 
hundred ovariotomies he informed me he had never lost a 
patient by the anaesthetic. 

The mixture is given in almost every instance by 
means of the starched towel. 

Dr. B. Willis Richardson,* of Dublin, writes: "I 
confess that I am myself in favor of a mixture of equal 
parts of chloroform and spirits of wine for producing 
anaesthesia, and, therefore, it is the comparative safety 
of this fluid I propose testing against the ether" (but he 
gives no results). The mortality caused by a mixture 
of chloroform and ether given b}' inhalations is 2 to 
11.176, or 1 to 5.588. With this mixture of chloroform 
and alcohol, when administered from a handkerchief or 
sponge, according to u Snow," very little of the spirit is 
inhaled, as the greater part remains behind after the 
chloroform has evaporated ; but it acts by lowering the 
amount of vapor which is given off, just as diluting a 
strong solution of ammonia with additional water di- 
minishes the amount of the volatile alkali which escapes 
as gas. One hundred cubic inches of air are capable of 
taking up fourteen cubic inches of vapor, at 60°, from 
pure chloroform, and becoming expanded to 114 cubic 
inches; but, when the chloroform is diluted with an 
equal volume of alcohol, it will onl}' yield eight cubic 
inches of vapor to 100 of air. In passing over a 
sponge or handkerchief the air would take up less than 
this, usually four or five per cent., which is a quantity 
sufficient to cause insensibility without the risk of sud- 
den accident, in four or live minutes. The same result 
is produced in the mixture of ether and chloroform. 
Dr. Atlee is of the opinion that there is a chemical union 
of the ether and chloroform ; and Professor Maisch, of 
this city, found that, if this mixture was exposed to the 
light, a change took place which rendered the mixture 
not lit for the purposes of inhalation ; it therefore should 

* Op. cit. 25. 



MIXTURE OF ETHER AND CHLOROFORM. 61 

be kept from the light, and mixed just before being em- 
ployed. Dr. Atlee keeps his mixture in a bottle and in 
a tin case. In less careful hands than those of Dr. Atlee 
the chloroform is apt to result fatally, as is shown in the 
records of the following case : — 

A death of a lady had occurred in the practice of 
Dr. Eastham, a dentist of Boston, causing much excite- 
ment in professional circles. The death had taken place 
about noon, but very few, except those particularly in- 
terested, were aware of it till the next day. The coro- 
ner, Dr. Ainsworth, who was called in directly after the 
accident, formed a jury of physicians and apothecaries, 
and ordered an autopsy. This was made the next morn- 
ing by Dr. E. H. Fitz, pathologist to the Massachusetts 
General Hospital; and on the same day the jury met, 
and, having viewed the body, adjourned until the 14th. 
The anaesthetic was either chloroform or a mixture of 
chloroform and ether. The latter proves to be the one 
used. The jury met again on the 14th, and, having heard 
a part of the evidence, readjourned till the evening of 
Wednesday the 19th. We present the following ac- 
count of the proceedings :* On November 14th, the first 
witness was Dr. Edson, who testified that he had twice 
attended Mrs. Crie, the deceased, during her confine- 
ments, but had never given her an anaesthetic, though 
she had desired it. This was owing to his disapproval 
of anaesthetics during labor, except in rare cases. He 
would have given one to the deceased as readily as to 
any patient in her case. 

Dr. Fitz was next called, and read the following ac- 
count of the autopsy : — 

Examination made twenty-one hours after death. 
Body preserved in ice ; rigidity well marked ; no dis- 
coloration of face or anterior portions of the body ; 
skullcap and dura mater normal ; longitudinal veins 
empty ; moderate amount of blood in the veins of the 
arachnoid ; nothing abnormal observed at the base of 
the brain. The bloodvessels in this region contained but 
little blood ; cerebral substance firm, containing much 
less blood than usual, not particularly moist ; absence 
of any anatomical changes ; ventricles apparently nor- 

* Boston Medical and Surgical Journal, November 20, 1873. 



68 ARTIFICIAL ANESTHESIA. 

mal. Pericardium healthy. Heart moderately contract- 
ed, unusually small, and of usual color ; aorta of less 
than the normal calibre, walls unusually thin and elas- 
tic ; cavities of the heart contained dark fluid blood, of 
no unusual odor or color; right side of the heart con- 
tained more blood than the left; valves healthy, muscu- 
lar substance apparently normal. Pleural cavities 
healthy, containing a small amount of reddish fluid. 
Lungs of a bluish-red color, the posterior dependent 
portions quite dark ; tissue contained air and a some- 
what increased amount of blood ; absence of any special 
degree of oedema; in upper lobes of both lungs a rare, 
small, cheesy nodule. The larynx, trachea, bronchial 
tubes, and the larger vessels at the root of the lungs 
free from changes. Spleen of normal size and firmness, 
the color dark blue. Kidneys unusually firm, capsule 
rather more adherent than usual ; in sections, the organ 
was of a grayish-slate color; bloodvessels, including the 
Malpighian organs, unusually distinct from the presence 
of blood ; tubular structure apparently healthy. Blad- 
der healthy. Uterus and ovaries well developed ; an old 
corpus luteum present ; the lining membrane of the body 
of the uterus unusually injected, covered with a viscid, 
blood}- fluid. Liver of normal size, dark color, contain- 
ing rather more blood than usual, otherwise healthy ; 
stomach and intestines presented no unusual appear- 
ances. 

The anatomical examination gave no evidence of recent 
disease of an}' of the organs, or of chronic alterations 
sufficient to account for death; the fluid conditions of 
the blood, the diminished amount in the brain and the 
increased amount in the thoracic and abdominal organs, 
were abnormal, and might have been the result of various 
causes; the diminished size of the heart and of the aorta 
were probably of congenital origin. 

Question. Do }'Ou consider the absence of blood in the 
brain and cerebral cavities as abnormal? Answer. Yes, 
sir. 

Q. Do you ever find the blood liquid so long after 
death, except where chloroform is used? A. Yes, sir; it 
is so in any case of death from asphyxia, in cases of 
poison from certain gases, and in cases of some very 



MIXTURE OF ETHER AND CHLOROFORM. 69 

malignant forms of disease where decomposition is very 
rapid. 

Q. I suppose a perfectly healthy woman would not be 
likely to have this sudden change take place in her with- 
out some cause similar to those you have mentioned ? 
A. Veiy unlikely. 

Dr. Eastham then testified that he graduated in medi- 
cine in 1841, had practised dentistry nearly all the time 
since, and had used anaesthetics from their introduction. 
The deceased had been his patient for twelve or fourteen 
years, during which he had on several occasions given 
her anaesthetics — chloroform, ether, and gas — both se- 
verally and in combination. The deceased came to his 
office in the forenoon of the 10th, and there met Mrs. 
Sawyer, whose tooth he extracted after giving nitrous 
oxide. Mrs. Sawyer urged the deceased to take gas, but 
she insisted upon ether. He made a mixture of a little 
chloroform and ether. 

Question. You made a mixture at the time ? Answer. 
Yes, sir; I usually do that way. 

Q. Please tell me whether or not on this occasion you 
measured the quantity ? A. No. I have been so fami- 
liar with it that I usually guess at the proportion. I 
never measure it. I always calculate to have more ether 
than chloroform. 

Q. How much of this mixture did you make ? A. Not 
more than an ounce or an ounce and a half. 

Q. How did you administer it ? A. I always admin- 
ister it on a sponge. I always drop the window at the 
top, so as to have fresh air. I pour on to this sponge 
(it is a hollow one about the bigness of my two hands) 
about a big teaspoonful, as near as I can judge. 

Q. That would have been about a third of the mixture? 
A. No, not so much as that. I always begin gradually 
in applying it, first holding the sponge a little distance 
from the nose and then moving it nearer. As she began 
to breathe it, she said, u Give me enough this time, sure." 
This she repeated three times. I did not fully etherize 
her, nor did I intend to. After she had breathed two or 
three minutes, I said to her, " I am going to take this 
tooth out." She shook her head, as much as to say she 
was not ready, but I took hold of the tooth. She straight- 



70 ARTIFICIAL ANAESTHESIA. 

ened back, groaned and screamed a little as if in pain. 
After I had pulled the tooth, she went back into a sort 
of hysterics, and became rigid, as if in spasms. 

Q. At this point in the case, did you notice her lips, 
whether they were pale? A. Not much. 

Q. Any change in her countenance? A. Not much. 

Q. Did you notice her eyes? A. They were set, wide 
open, like one in a spasm. 

Q. You did not notice whether there was anything 
particular about the lips ? A. No. 

Q. Did you try the pulse at that time? A. Xo. I 
seized a napkin, moistened with water, and gave her a 
splash on the forehead. She seemed to revive, and I saw 
a flush of color come over her face. I set her up and 
took my ammonia water and applied that to her nose ; 
then I spoke to Mrs. Saw3'er. Mrs. Crie was sitting up 
in the chair, inclined a little forward at that time, and I 
was applying ammonia and water to the face. Mrs. 
Sawyer came in, and I asked her to loosen her dress, 
which she did. Then I saw a change again, back to pale- 
ness, and I said, "Call the other doctors." Dr. Osgood 
arrived first. We unloosed Mrs. Crie's corsets. Dr. 
Osgood rubbed her spine, and I sent the porter after 
another physician. We continued to rub her and apply 
very strong ammonia, and, finall}', after Dr. Lamson 
came in, we removed her to the large room, and, raising 
her arms, tried in every way to set up respiration. We 
sent for a battery and used that. We worked over her 
till we all came to the conclusion that she was past all 
restoration. 

Q. Can you tell us how long after she fell back into 
this spasm it was before respiration ceased? A, I should 
say about fifteen minutes. 

Q. How long did the flush continue? A. It might 
have been two minutes. 

Q. Then, as I understand, she fell back at once ? A. 
As soon as the shade went back, 1 called for help. After 
administering these anaesthetics, there are two peculiar 
shades. There is the shade for faintness, and a shade 
from sickness at the stomach, and they are perfectly 
distinct. 



MIXTURE OF ETHER AND CHLOROFORM. 71 

Q. What was j T our opinion of this peculiar shade then ? 
A. I thought it was a pallor from faintness. 

Q. From the time she had this spasm, and during the 
time you were administering the ammonia, was she sitting 
up in the chair? A. Yes, sir; but after the doctors 
came in thej' removed her to the waiting-room and laid 
her down. 

Q. Was she breathing then? A. She was dead. 

Q. How long had you begun the administration of 
ether before you extracted the tooth ? A. About a 
minute or a minute and a half. 

Q. During that time did you feel no pulse? A. Never 
do that. Always watch the side of the head, the tem- 
poral artery. 

Q. Do you think there is any danger of death occur- 
ring from giving ether alone? A. I never had anything 
that appeared like it myself ; nor in chloroform. 

Q. You have not considered then that there was any 
danger ? A. No, I do not — that is, unless you administer 
it as they do in England. I should think they would kill 
every other one, by using a napkin as they do. But if 
chloroform be given as 1 give it, on a sponge, with plenty 
of fresh air, I don't consider it any more dangerous than 
ether; but a person must discriminate between individ- 
uals, whether he would give ether, or gas, or chloro- 
form, or anything, and these things must be learned by 
practice. 

Q. You considered her to be a person lacking some- 
what in vitality, and therefore you didn't choose to put 
her fully under the influence of it (the anaesthetic)? A. 
Yes, sir. 

Q. Do you consider either of these anaesthetics more 
dangerous than the others ? A. I suppose chloroform 
would decompose blood quicker than ether. 

Q. Do yon know of any difference in chloroform? A. 
I have never used but one kind, Squibb's. 

Q. In what way do you keep it ? A. Always in a dark 
closet and corked as tight as I cnn. 

Q. Do 3 7 on know of any difference in the quality of 
ether? A. No, only from the seller's opinion of it. I 
use Powers & Weightman's concentrated. 

Q. How much of this mixture did you generally make 



72 ARTIFICIAL ANESTHESIA. 

at a time? A. Not more than a couple of ounces at 
once. 

Q. What was the proportion of chloroform that you 
generally intended to have in ? A. Less than half, by 
volume. 

Q. Did you keep that mixture a long time ? A. No, 
but I would most always add more ether if it had been 
standing a little while. 

Q. Did you state that you made this mixture you ad- 
ministered to Mrs. Crie that day ? A. I had a little in 
a bottle, and I added more to it before I gave it to her. 
I had used it a week before. 

Q. What is your reason for adding chloroform to the 
ether? A. Well, I think it is safer. Ether is a great 
stimulant, and when you have a little chloroform, the 
patients are not so noisy or excited as they are under 
pure ether. That is my reason, not that I feared one or 
the other. 

Q. You would not hesitate to give an}' quantit}' of 
chloroform? A. No, sir. If amputation was to be per- 
formed I would as soon use chloroform as ether. 

Q. On the whole, which anaesthetic do you consider 
the most safe ? A. I think I should use ether for safety. 
Ether and chloroform combined, in my idea, is much bet- 
ter than either of them alone. 

Q. Do you feel any anxiety when about to administer 
chloroform or ether or the mixture? A. No. 

J n the above case, instead of death resulting from 
ether, it was, as was proven by analysis, due to chloro- 
form, and the coroner's jury presented the following 
verdict, " death was caused by the inhalation of chloro- 
form, administered in a mixtureof chloroform and ether."* 

Methylic Ether. 

Are there any other ethers which can be employed 
with safety, and what is the best method of employing 
them? Dr. Richardson, of London, has used methylic 
ether, which he regards as one of the best (after sul- 
phuric). This conclusion, it is stated, he reached after 
experimenting with eight or ten of the best known anaes- 

* Bostou Medical and Surgical Journal, Nov. 27, 1873. 



BICHLORIDE OF METHYLENE. 73 

thetics. He prefers a solution of nieth\dic ether in ethy- 
lic ether, which latter will take up more than one hundred 
volumes of the methylic-ether gas. This mixture he then 
styles methylic ether. In Dr. Carter's work, before 
quoted, he states, " In Dr. Richardson's own hands, I 
have seen the various (new) ethers act perfectly well, 
producing complete unconsciousness and relaxation of 
muscle without either struggling or sickness, and with- 
out unpleasant symptoms of any kind ; but I cannot 
judge how far such results may have been due to the 
qualities of the agents employed, how far due to spe- 
cial^ skilful or careful administration, or how far to the 
state of the patients themselves." Bichloride of methy- 
lene was introduced by Dr. B. W. Richardson in 1867, and 
it has been employed not only in short operations, but also 
in such operations as ovariotomy. "Of this agent, Dr. 
Jones,* of Cork, has had considerable experience, having 
used it constantly for all minor operations in hospital 
and private practice for over seven years. Hard drinkers 
or old tipplers bore this form of anaesthetic badly, and 
on some occasions he has been alarmed and compelled 
to desist from its administration. He also found it to 
be dangerous in old cases of chest affection. His mode 
of administration was in a conical gauze bag lined with 
flannel, and containing a small sponge." 

Bichloride of Methylene. 

For some .years, the bichloride of methylene has re- 
ceived the fullest trials at Moorfields Ophthalmic Hos- 
pital, London, where they now (1876) use almost exclu- 
sively sulphuric ether. Within the two years' trial of the 
bichloride of methylene in the hospital above referred to, 
two deaths occurred without any indication of danger 
from the state of the pulse or heart. In the last instance 
of death it occurred from the exhibition of one drachm 
and a half of methylene to a healthy sailor, aged twenty- 
seven years. Bichloride of methylene is employed in the 

* Medical Responsibility in the Choice of Anaesthetics. By H. 
M. Jones, M.D., Surgeon of Cork Ophthalmic Hospital. Cork, 
1876. 

•7 



74 ARTIFICIAL ANAESTHESIA. 

Samaritan Free Hospital of London, and the officer in 
charge of the anaesthetic states it to be very satisfac- 
tory. Junker's form of apparatus is used for its admin- 
istration. 

The mortality from this agent is 2 in 10,000 or 1 to 
5000 

As I have stated above, the strongest advocate for 
the bichloride of methylene or chloromethyl is Mr. J. 
Spencer Wells, who believes that with this agent he has 
had all the advantnges of complete anaesthesia with fewer 
drawbacks than any other. This is his experience of five 
years, and of three hundred and fifty serious operations. 
He gives it diluted with air by Junker's apparatus, and, 
from his doubts of its composition, we suspect what he 
employs to be a mixture of methylic alcohol and chloro- 
form ; these are his own words. But whatever may be its 
chemical composition, whether it is chloroform mixed 
with some spirit or ether, or whether it is really bichlo- 
ride of methylene, I am still content with the effects of 
the liquid sold under that name. — Meeting British Medi- 
cal Association, 1877. 

Dr. Taylor* also states, that " a mixture of chloroform 
and ether has been sold as bichloride of methylene. On 
shaking this mixture with water, the chloroform is sepa- 
rated and sinks." He reports three deaths from this 
agent, and the allegation, therefore, that the vapor pos- 
sesses any greater degree of safet3 r than chloroform in 
surgical practice, is not supported by facts. 

Death from the Bichloride of Methylene. 

Case 1. — A death from bichloride of methylene took 
place at the Ipswich Hospital, England, which affords a 
remarkable illustration of the relative safety of that 
drug and of ether. The patient was 56 years of age, 
and w T as to have had a necrosed bone removed from his 
leg. He was first given the methylene, which was 
changed for ether for some cause which is not stated, 
but which may have been some alarming symptom pro- 
duced by the methylene. Having taken the ether with 
safety until anaesthesia was obtained, the operation was 

* On Poisons, op. cit. p. 629. 



AMYLEN. 75 

proceeded with, but, the patient being allowed to wake 
too soon, the methylene was again resorted to. In fif- 
teen seconds he was dead. No post-mortem examination 
was made, but some ingenious person hazarded a guess 
that there had been unobserved apoplexy, and the jury, 
happy at any alternative except condemnation, adopted 
the hint, and voted the death accidental, and the medical 
officers free of all blame. A most unsatisfactory case 
in all its aspects, and one which should please the medi- 
cal officers inculpated less than any one else. Such a 
fatality may be hidden awa} r by such a verdict, but no 
one can be satisfied, without evidence, that the case was 
not one of anaesthetic manslaughter. — Medical Press, 
London. 

Case 2. Pharmaceutical Journal, 1871, p. 875. Male, 
set. 40. Given during an operation on the eye. Result, 
death in five minutes. Post-mo7*tem, congestion of the 
lungs. 

Case 3. Pharmaceutical Journal, 1871, p. 875. Male. 
Inhaled 5iss. Result, death rapid. Post-mortem, no 
special post-mortem appearances. 

Case 4. Lancet, Oct. 23, 1869, p. 5S2. Mr. Marshall. 
Male, a?t. 39, 3i ss « The man was sitting in a chair dur- 
ing the time of administration, and preparing for an 
operation. S} r mptoms, pupils slightly dilated ; no ster- 
tor or livid ity of countenance. Result, death. 

Case 5. One of the most painful cases of death from 
the vapor of methylated ether occurred in the Birming- 
ham Hospital, England, under Mr. Tait. A patient was 
about to undergo the operation of ovariotomy. Five 
drachms of methylated ether in vapor were administered 
to her on a fold of a towel, by the resident medical 
officer. The pulse suddenly stopped, the pupils became 
dilated, and respiration ceased. All efforts at restora- 
tion were fruitless. On inspection of the heart and all 
the other organs they were healthy except the ovary. — 
Lancet, July~5, 1873, p. 23. 

Amylen. 

The vapor of this liquid was introduced by the late 
Dr. Snow as a substitute for the vapor of chloroform. 
It produces a loss of sensibility without causing com- 



76 ARTIFICIAL ANiESTHESTA. 

plete coma or stupor. Its use has already led to at least 
two deaths, and is, according to Dr. Taylor,* not so safe 
an agent as chloroform vapor for surgical purposes. 
The only appearance met with in one fatal case was an 
emphysematous state of the lungs, or excessive dilata- 
tion of the air-cells {Med. Times and Gaz., April 4 and 
18, 1857, pp. 332, 381), and in the other a distension of 
the right cavities of the heart with dark fluid blood. 
There was no congestion of the brain, and no smell of 
am}den perceptible in the body. — Med. Times and Gaz., 
Aug. 8, 1857, p. 133. 

Bromide of Ethyl or Hydrobromie Ether. 

Bromide of ethyl (C. 2 H 5 B), or " hydrobromie ether," 
is a colorless liquid with an agreeable odor ; it boils at 
about 40° C, has a density of 1.43, and burns with difli- 
cult} r . The boiling point and density are, therefore, in- 
termediate between those of chloroform and sulphuric 
ether. Bromide of ethyl absorbed by the respiratory 
passages produces, according to M. Rabuleau, of Paris,f 
absolute anaesthesia as rapidly, or even more rapidly, 
than chloroform. This result has been established with 
frogs, rabbits, dogs, etc. After five minutes' (sometimes 
after two minutes') inhalation by means of a sponge 
saturated in bromide of ethyl, dogs were completely 
anaesthetized. The animals recovered more rapidly than 
when chloroform was used. 

Bromide of ethyl is not caustic, nor even irritant, when 
compared to chloroform. It can be ingested without 
difficulty, and applied without danger, not only subcu- 
taneousty, but to the external auditory meatus, and to 
the mucous membranes. In this respect it is preferable 
to chloroform, which is very caustic, and to sulphuric 
ether, of which the ingestion is nearly impossible. In- 
troduced into the human stomach in doses of from one 
to two grammes, bromide of ethyl does not produce 
anaesthesia as when absorbed in sufficient quantity by the 

* On Poisons, op. cit. p. G27. 

f Comptes Rendus, vol. lxxxiii. p. 1294; Pharm. Journ. and 
Trans. 



BROMIDE OF ETHYL. 77 

respiratory passages. It soothes pain and does not dis- 
turb the appetite. 

This hydrobromic ether is nearly insoluble in water; 
nevertheless, water shaken with it acquires a pleasant 
taste and odor. Frogs placed in water so saturated 
undergo anaesthesia in ten or fifteen minutes. It is 
eliminated nearly entirely, if not completely, by the 
respiratory passages, whatever may have been the mode 
of absorption. At most, only traces of it are found in 
the urine when it has been introduced into the stomach, 
and an extremely small quantity can be detected in that 
secretion when it has been inhaled. Bromide of ett^l 
does not decompose in the organism to form an alkaline 
bromide. Bromide of ethyl is an anaesthetic agent pos- 
sessing properties intermediate between those of chloro- 
form, bromoform, and ether. I have experimented with 
this ether, prepared for me by Prof. Jos. P. Remington, 
of this city. 

This ether was discovered by Serullas in 1827. It is 
produced by the action of bromine, hydrobromic acid, 
or bromide of phosphorus on alcohol. 

The method which Mr. Remington emplo} T ed was that 
of the celebrated chemist De Vrij, by distilling 4 parts 
pulverized bromide of potassium, with 5 parts of a mix- 
ture, of 2 parts strong sulphuric acid and 1 part alco- 
hol of 96 per cent. 

Properties. — Transparent and colorless liquid, heavier 
than water (Serullas); specific gravity 1.40 (Lowig), 
1.4733 at 0° (Pierre); vapor density 3.754 (R. Mar- 
chand J. per cm. 188) ; very volatile; boiling point 40.7° 
C. when the barometer stands at 757 mm. (Pierre) ; has a 
strong ethereal odor and pungent taste (Serullas). Ac- 
cording to Lowig, its taste is strongly and disagreeably 
sweetish, with a somewhat burning after-taste. The 
vapor, when inhaled, exerts an anaesthetic action, like 
chloroform (Robin, Compt. Rend, xxxii. 669). It is spar- 
ingly soluble in water, but mixes in all proportions with 
alcohol and ether. 

Decompositions — 1. Yapor of hydrobromic ether passed 
through a glass tube at a low red heat is resolved into 
ethylene and h} T drobomio acid gas. 2. It burns with 
difficulty, but with a beautiful green flame, which does 

7* 



78 ARTIFICIAL ANESTHESIA. 

not smoke, a strong odor of hydrobromic acid being at 
the same time evolved. 3. It is not decomposed by 
nitric acid, oil of vitriol, or potassium. 4. With am- 
monia it yields hydrobromate of ethylamine. 

The first experiment was upon a small quantity, and 
subsequently upon four ounces. I found it to contain 
all the phy sical qualities as described by M. Rabuleau. 
It was colorless, with an agreeable odor and pleasant 
taste. The boiling point, 40.9° C, and its density 
heavier than water. When inhaled, it produced more of 
the agreeable effects of chloroform, and did not increase 
the pulse over its normal beat, whilst its action was very 
rapid, and in the second state it caused an intermission 
of the pulse every second beat. Three teaspoonfuls 
were added to a pint of water, and they sank to the bot- 
tom in globules, and upon being shaken it was in part 
diffused in the water without producing any change in 
the color. A large-sized lively frog was then placed in 
this pint of water thus charged, and he made numerous 
endeavors to get out of it, and it required twenty min- 
utes before he was fully under its influence. The anaes- 
thetic effect was most profound ; even his heart could 
just be felt making a most feeble effort, and his respira- 
tions entirely ceased, as far as I could judge. He was 
perfect^ relaxed ; the extremities became a livid-red 
color, and apparently lifeless, and no pinching or 
pricking was felt by him. After the frog had been re- 
moved he remained in this state for fifty-eight minutes, 
and then began to make some slight movements, and, 
when the hour was up, was able to move about in a 
languid manner. 

Owing to the peculiar action on the pulse, I feared 
the hydrobromic ether might not be perfectly free from 
some toxic agent, so I took the specimen back to Mr. 
Joseph P. Remington, and he carefully redistilled it over 
lime, and he stated in a note to me that it was now per- 
fectly pure. The boiling point is 40.0° C, or about 104° 
Fahr. This very nearly corresponds with Pierre's ob- 
servation, i. e., 40.7° C, density 1.43 ; burns with diffi- 
culty, producing a greenish flame. 

I made the following experiment with it in the ear: 
A teaspoonful was mixed with one of glycerine, and was 



BROMIDE OF ETHYL. T9 

placed in the ear of a patient who was suffering from 
otalgia. The patient stated it gave her some pain, with 
a feeling of heat ; but these sensations soon passed 
away, and her pain was relieved. No inflammation or 
caustic effects resulted from its use in the auditory 
canal, which was very irritable. I attempted to use a 
small quantity of chloroform on cotton in the same ear, 
but it could not be borne in contact even for a few sec- 
onds, it caused so much distress and irritation of the 
parts. 

When hydrobromic ether is administered by the 
mouth, it should be triturated with glycerine, gum- 
arabic in powder, or a small portion of spermaceti, as 
it is so much heavier than water, and its effect upon the 
mucous membrane is slightly irritating if not given 
properly (mixed), as it produces a feeling of warmth, 
and, as usual, eructation of gaseous ether. A third use 
of it, by inhalation, on a patient about to undergo a 
painful operation, induced a slight feeling of nausea, 
and she was very rapidly brought under its influence, 
and it did not produce the intermission in the pulse as 
in the first case. In two cases in which the ear was in- 
flamed this preparation of ether could not be borne by 
the patient even on cotton. 

Mr. Remington made me a second specimen of hydro- 
bromic ether by the use of phosphorus, which I in- 
haled myself, and also administered to a patient, and 
found it was free from the irritating effects upon my 
lungs and heart. In certain cases where ordinary sul- 
phuric ether was objectionable, this ether might be sub- 
stituted. It evidently holds an intermediate place 
between chloroform and ether, and is worthy of a more 
extended trial. 

One of the common impurities of hydrobromic ether 
is bromoform, CHB 3 , produced b} r the simultaneous 
action of bromine and caustic potash on wood spirit, 
alcohol, or acetone ; also by action of bromine on 
acetous, citric, or malic acid ; and by decomposing 
bromal with alkalies. It is a limpid liquid of sp. grav. 
2.13, having an agreeable odor and saccharine taste. It 
is less volatile than chloroform, very little soluble in 
water, to which, however, it imparts its taste and odor ; 



80 ARTIFICIAL ANESTHESIA. 

soluble in alcohol, ether, and essential oils. It burns 
with difficulty. — Watts's Dictionary of Chemistry, Lon- 
don, 1872. 



CHAPTER IV. 

Chloroform, chemical composition, impurities, tests. Recent investiga- 
tions, by Bowditch, of Boston. Deaths from chloroform in England. 
Aid of the legislature to stop the employment of chloroform in France. 
Mode of use in Scotland, by Professor Macleod, with form of apparatus, 
and all the necessary precautions in case of impending death. Report 
of twenty-one cases of chloroform administration. Dr. Allis' Chloro- 
form Inhaler. Employment of anaesthetics in labor. M. Pichard. 
Congress at Geneva. Drs. Lusk, Wilson, and Smith. Statistics of 
death from chloroform, by the late Dr. Morgan, of Dublin. Dr. Sims 
on Nelaton's method. Nitrite of iitnyl as an antidote to chloroform. 
Observations and cases, by Drs. Richardson, Burrall, Lane, and 
Munde. Dr. Clover's inhaler. Mixed narcosis, use of morphia 
before inhalation of chloroform. Dr. Richardson's experimentation 
upon reported deaths from chloroform, etc. Conclusions in reference 
to the use and safety of chloroform, by Drs. Chisholm, Erichsen, and 
Gross. 

Chloroform. 

Chloroform; dichlorinated chloride of methyl; ter- 
chloride of formyl, CHCP. Chloroform was dis- 
covered in 1831, by " Soubeiran, Guthrie, and inde- 
pendently in 1832, by Liebig." Its true constitution 
was discovered by Dumas, in 1834. The most economi- 
cal method of preparing chloroform is the distillation of 
alcohol with chloride of lime. 

Chloroform may be contaminated with alcohol, ether, 
and empyreumatic oils. Pure chloroform sinks in a 
mixture of equal parts of oil of vitriol and water. Ac- 
cording to " Kessler," chloroform containing alcohol 
diminishes in volume on the application of this test. 
The presence of alcohol causes opalescence when the 
chloroform is mixed with water, whereas, pure chloro- 
form remains clear. Chloroform containing alcohol ac- 



CHLOROFORM. 81 

quires a green color when mixed with chromic acid or 
with sulphuric acid and acid chromate of potassium. 
Pure chloroform produces no green color. Chloroform 
prepared from wood spirit is much less pure than that 
obtained from alcohol. The former is specifically lighter 
than the latter, has a repulsive empj^reumatic odor, and 
produces unpleasant sensations when inhaled. Accord- 
ing to Gregory, impure chloroform may be recognized 
by the disagreeable odor it leaves after evaporation on 
a cloth which has been moistened with it, and by the 
yellow or brown color which it imparts to pure oil of 
vitriol when agitated therewith. 

Pure chloroform placed upon oil of vitriol produces a 
contact-surface convex downwards ; impure chloroform 
gives a plane contact-surface. According to Roussin, 
the purity of chloroform may be tested by means of 
dinitrosulphide of iron, Fe 6 H'S 5 N*0 2 (a salt obtained by 
the action of ferric chloride or sulphate on a mixture of 
sulphide of ammonium and nitrite of potassium). Pure 
chloroform shaken up with this salt remains colorless ; 
but if it contain alcohol, ether, or wood-spirit, it ac- 
quires a dark color. Pure chloroform is a transparent 
and colorless liquid, of specific gravhy 1.491 at 17° C. It 
boils at 61° (Regnault). Its vapor density is 4.199 ac- 
cording to Dumas, 4.230 according to Regnault. Chlo- 
roform remains liquid and transparent at — 16° C, and 
may be solidified by the cold produced by its own evapo- 
ration. It has a very pleasant penetrating odor, a sweet 
fiery taste. Chloroform preserves meat, 200 times its 
weight, from putrefaction. 

Chloroform dissolves slightly in water, imparting its 
sweet taste to the liquid. It mixes in all proportions 
with alcohol. 

Chloroform decomposes when exposed to air and light, 
with the formation of chlorine, hydrochloric acid, and 
other products, but when kept under water it remains 
unaltered. 

This is the second agent of importance in use as an 
anaesthetic, and one of the most powerful and most 
agreeable of all the forms. It is also the most rapid in 
its action and less under our control than ether. It has 
been found by the recent investigations of Dr. Henry I. 



82 ARTIFICIAL ANAESTHESIA. 

Bowditcli,* of Boston, that ether and " chloroform re- 
semble each other in their effects on those nerve centres 
whose activity is connected with the conscious percep- 
tion of pain. The latter, however, acts much more pow- 
erfully than the former upon those centres which regu- 
late the arterial blood tension, and thus effects profoundly 
the condition of animal life. Ether and chloroform are 
both anaesthetics, but chloroform is something more." 
And what is this something more? Namely, great pros- 
tration without warning. 

In England, it has been stated that the deaths from 
chloroform are at the rate of one a week during the 
year. It has been proposed in France to seek the aid of 
the legislature to put an end to its employment. In 
Scotland,f it is stated that it is not the chloroform which 
is to blame, but the mode of administration, and yet 
there is nothing new in their method, ov\\y great care, 
with all the materials at hand in case of fainting, asphyxia, 
sudden paralysis of the heart, and one carefully in- 
structed person who takes the entire charge of this pow- 
erful anaesthetic. 

Report of Twenty-one Cases Chloroform Administration. % 

Min. Sec. 
Shortest time taken to place the patient under 

anaesthetic influence of chloroform, 
Longest time, 
Average, 

" time under influence, 

Smallest quantity used in any one case, 1 drachm, 
Largest " " " " 8 " 

Average " " " " 3 " 

Great Prostration in one Case after Administration. 
— The chloroform was administered by means of a hand- 
kerchief or towel folded in the form of a cone. 

* The Influence of Anesthetics on the Vaso-motor Centres, by 
Henry I. Bowditcli and C. S. Minot. Boston, 1874. 

f On the Administration of Chloroform, by George H. B. 
Macleod, M.D., Professor of Surgery, University of Glasgow. — 
Brit. Med. Journal. 

% By Surgeon-Major J. IT. Porter, Assistant Professor of Mili- 
tary Surgery, London, 1875 ; Netley Hospital ; Erichseu's Sur 
gery, p. 50, Phila. 1878. 



2 


30 


14 


30 


u 


24 


12 


48 


9 minims. 



CHLOROFORM. 83 

Vomiting occurred in 2 cases after the administration 
of the drug; excitement occurred in 10 cases during or 
after administration. 

The following is a description of a simple form of in- 
haler for the administration of chloroform, devised by 
Dr. Allis, of this city.* See Fig. 16. 

" It consists merely of two tin cones soldered apex to 
apex, with a tube projecting from the upper or receiving 
cone into the lower. Around the base of the larger cone 
a piece of linen is tied. When the instrument is to be 
used, a towel is properly folded and pinned around the 
larger cone, presenting, when complete, a cone of suffi- 
cient size to cover neatly the mouth and nose. 

" This cannot be called an inhaler with any more pro- 
priety than can a towel or a napkin ; but, while it re- 
sembles the latter in principle, it has in 
practice very many and important ad- Fig. 16. 

vantages. 

" 1. The chloroform falls through the 
tube upon a single layer of linen to 
both sides of which the air has ready ac- 
cess, and is accordingly instantly evapo- 
rated. 

" 2. Every drop is conveyed to the 
patient. 

" 3. A few drops at a time are all that 
are ever required, and all the patient can 
breathe with comfort. 

u 4. The dropping may be more or less constant, as 
the instrument need not be removed from the face, and 
by means of a 'dropper' (see Fig. T), the operator can 
gauge the amount to the necessities of the case. 

u 5. The anaesthetic influence is gained gradually, im- 
perceptibly, and rapidly, and with a minimum amount of 
chloroform. I seldom use more than a drachm and a half 
in adults. 

" 6. As onty a few drops need be added at a time, the 
danger must be far less than when an indefinite quantity 
is poured on from a bottle at once. 

" 7. There is no exclusion of the air, but the air that 

* Philadelphia Medical Times, Number 162. 




84 ARTIFICIAL ANESTHESIA. 

is breathed is impregnated with a fresh supply of chloro- 
form. 

" 8. The time consumed is usually from three to ten 
minutes. 

" 9 The influence once obtained may be easily main- 
tained. 

" We have used this repeatedly for nearly four years, 
and have found it all that we could desire. 

" It is exceedingly convenient as a frame-work about 
which to pin the towel, and as a receiver of the chloro- 
form, and so simple in construction that any tinsmith 
could make or repair it should it be broken. 

"As to Us rendering the use of chloroform safe, I can 
only say that safety does not lie in an inhaler, but in him 
who uses it."* 

M Chloroform is eight times more dangerous than ether. 
When to the deaths by chloroform we add those not in- 
frequent chloroform accidents, where artificial respiration 
alone restored the patient, when life was hovering on ex- 
tinction, and when the faintest attempt at respiration 
was so anxiously watched for, and heard with such in- 
tense relief (though such cases do not come under imme- 
diate publicity), it must indeed be admitted the}" would 
tend very much to intensify the distrust which is more 
or less acknowledged, and is the real impediment of this 
' pain destroyer,' when we are about, by its means, to 
use the words of a modern surgical writer,*)" reducing 
the patient to a condition in 'which, to the uninitiated, 
he appears in articulo mortis,' and in 'which very little 
more would place the circumstances in a most critical 
relation.' " 

Dr. M. Sims, of New York, considers that it is the 
safest plan to relinquish the use of chloroform altogether 
except in obstetrics. Yet, in this department, deaths have 
occurred from chloroform, one very recently. Prof. De- 
paul, of Paris, has stated that sudden deaths from the 
obstetric use of chloroform are not unknown to him. 

We give the following case recently reported: " Death 
from chloroform at the Lyons Maternite." 

"A young woman, twenty-five years of age, who had 

* Prof. Morgan, of Dublin, op. cit. 

t Prof. Miller, of Edinburgh (Surgery), p. 582. 



EMPLOYMENT OF ANAESTHETICS IN LABOR. 85 

already borne children, was admitted into the Maternity 
of theCharite, at 3 P.M. on March 23, 1876. The pains 
continued all night, and at about 7 A.M. of the 24th, the 
liquor amnii having been discharged, it was ascertained 
that there was a shoulder presentation. 

" In order to effect version, chloroform was adminis- 
tered, under the sole direction of the sister intrusted with 
the service ; neither the chef-de-service nor the interne on 
duty having been summoned to the case. 

M As, after the operation was terminated, the patient 
did not revive, the interne was now called, but the patient 
died ten minutes after his arrival. 

" The reporter justly observes that the death cannot 
be properly charged to chloroform without its being 
known what precautions were taken ; but, he adds, that 
such a circumstance should so happen in the first mater- 
nite of Lyons is indeed as astounding as deplorable." — 
Lyons Med., April 9. 

Employment of Anaesthetics in Labor. 

M. Piachaud read a paper before the International 
Medical Congress of Geneva (Gaz. Medicale, October 20, 
1877), in which he advanced the following conclusions, 
which are not generally approved of by the majority of 
gynaecologists, only a few holding to these views : — 

1. The employment of anaesthetics is, as a general rule, 
advisable in natural labor. 

2. The principal substances which have been used for 
this purpose up to the present time — chloroform, amylene, 
laudanum, morphia hypodermically, chloral by the mouth 
and by injection. 

3. Of these, chloroform seems to be preferable. 

4. It should be administered according to the method 
of Snow, that is, in small doses at the beginning of each 
pain, its administration being suspended during the in- 
tervals. 

5. It should never be pushed to complete insensibility, 
but the patient should be held in a state of semi-anaesthe- 
sia, so as to produce a diminution of the suffering. 

6. The general rule is never to administer chloroform 
except during the period of expulsion ; but in certain 

8 



86 ARTIFICIAL ANAESTHESIA. 

cases of nervousness and extreme agitation, it is advan- 
tageous not to wait for the complete dilatation of the os 
uteri. 

7. Experience has shown that anaesthetics do not arrest 
the contractions of the uterus or abdominal muscles, but 
that they weaken the natural resistance of the perineal 
muscles. 

8. The use of anaesthetics has no unpleasant effect on 
the mind of the mother or upon the child. 

9. In lessening the suffering, anaesthetics render a great 
service to those women who dread the pain ; they dimi- 
nish the chances of the nervous crises which are caused 
during labor by the excess of suffering; they make the 
recovery more rapid. 

10. They are especially useful to calm the great agita- 
tion and cerebral excitement, which labor often produces 
in every nervous woman. 

11. Their employment is indicated in natural cases 
until the pains are suspended or retarded by the suffer- 
ing caused by maladies occurring previous to or during 
labor, and in those cases where irregular and partial con- 
tractions occasion internal and sometimes continuous 
pain, without causing progress of the labor. 

12. In a natural labor, chloroform should never be 
used without the consent of the woman and her family. 

On the Necessity of Caution in the Employ- 
ment of Chloroform during Labor. 

Professor Lusk read a paper at the annual meeting 
of the American Gynaecological Society,* on the Neces- 
sity of Caution in the Employment of Chloroform dur- 
ing Labor. " He protested strongly against the popular 
idea that the administration of chloroform in obstetric 
practice was absolutely free from danger. In all cases 
in which a profound anaesthesia was produced by the 
administration of chloroform, the uterine action was 
weakened, and in some cases entirely suspended. It was 
extremely dangerous to continue the administration of 

* Reported in Boston Medical and Surgical Journal, June 7th, 
1877, p. 685. 



nelaton's method of resuscitation. 87 

the chloroform after the termination of the third stage, 
since in such cases there is great risk of a dangerous 
hemorrhage taking place. He believed that sudden 
death from the action of the chloroform, on the heart, 
was as liable to occur in obstetric practice as in cases of 
surgical operations." 

Dr. Wilson, of Baltimore, dissented from the views of 
the writer as to the danger of using chloroform in ob- 
stetric cases. 

Dr. Albert Smith, of Philadelphia, thought that 
chloroform was to be preferred to ether in those cases in 
which a rapid anaesthesia is to be desired. 

In a recent case, which came under the writer's notice, 
where three pints of chloroform had been employed in 
a tedious labor, there was great retardation, and ulti- 
mately, when the forceps were applied, the infant was so 
narcotized from the effects of the chloroform that every 
means employed to restore it failed.* 

A full account of Nelaton's Method of Resus- 
citation from Chloroform Narcosis. f 

Dr. Charles James Campbell, the distinguished ac- 
coucheur of Paris, has recently written two papers on 
anaesthesia in obstetrics, in which he ably sustains the 
views long taught by Neiaton, that death from chloro- 
form is due to syncope or cerebral anaemia. And 
amongst other strong arguments to prove his position, 
he gives a graphic description of a case of chloroform 
narcosis, which occurred in my practice in Paris, where 
M. Neiaton, by his method, unquestionably saved the 
life of the patient. She was young, beautiful, and ac- 
complished, and belonged to one of the oldest and best 
families in France. Married at twenty, she gave birth 

* In this case the baby's color, form, and features were most beau- 
tifully preserved by the chloroform for several days, without the 
use of ice, in hot weather. 

f Read at the forty-second annual meeting of the British Medi- 
cal Association, held in Norwich, August, 1874, by J. Marion 
Sims, M.D., Surgeon to the Woman's Hospital of the State of 
New York, etc. 



88 ARTIFICIAL ANESTHESIA. 

to her first child a year afterwards. The head was enor- 
mous (•hydrocephalic), impacted in the pelvis nearly 
twenty-four hours, and the deliveiy of a dead child was 
ultimately accomplished with instruments. Dr. Boucha- 
cour, of Lyons, was called in consultation, and applied 
the forceps. In a week afterwards the urine began to 
dribble awa} T , and in a fortnight an immense slough was 
thrown off. The case, surgically considered, was one of 
the most interesting I ever saw, and the operation was 
one of the most difficult I ever performed on any one in 
her station of life. The base of the bladder was de- 
stroyed, and the fundus fell through the fistulous open- 
ing ; it was therefore inverted, and protruded between 
the labia majora as a herniary mass of the size of an 
apricot, its external covering being the internal or lining 
membrane of the bladder, which was of a deep vermil- 
ion-red color. The vaginal portion of the cervix uteri 
and the posterior cul-de-sac were destroyed ; and l>3 r the 
reparative process the cervix and the posterior wall of 
the vagina were blended into one common cicatricial 
mass, which was firm, inelastic, and immovable. The 
case appeared desperate, and INI. N 61 a ton had pronounced 
it incurable. A preparatory operation was necessary, 
viz., to open the cervix uteri, by dissecting it from the 
posterior wall of the vagina, and thus to reconstitute 
the canal of the vagina up to the canal of the cervix ; 
and by a subsequent operation, to draw forward the 
flap thus formed, secure it to the neck of the bladder 
anteriorly, and thereby close the fistula. The first, or 
preparatory operation, was performed at the country 
house of the family, near Dijon, on November 3d, 1801, 
Dr. Dugast, of Dijon, assisting, and giving chloroform. 
The second, or operation for the radical cure, was per- 
formed on the 19th of the month, at St. Germain, about 
an hour's distance from Paris by rail. M. Nelaton, Dr. 
Campbell, Dr. Beylard, Dr. Johnston, and Mr., now Dr., 
Alan Herbert, were present. I seldom give an anaes- 
thetic in private practice for operation on the walls of 
the vagina, as the pain is generally not sufficient to call 
for it. But in this case, as the slightest touch was un- 
bearable, an anaesthetic was indispensable. Dr. Camp- 
bell was selected bj- the family, as well as by M. Nelaton 



CHLOROFORM IN GENERAL SURGERY. 89 

and myself, to administer the chloroform, especialty as 
he was in the daily habit of giving it in his large obstet- 
rical practice, and we all had entire confidence in his 
caution, skill, and judgment. The patient was soon an- 
aesthetized. The operation was begun at 10 A. M., and 
I thought it would require about an hour to finish it. 

Many years ago I imbibed the convictions of my 
countrymen against chloroform in general surgery, and 
have always used ether in preference, never feeling the 
least dread of danger from it under any circumstances. 
It is otherwise with chloroform, and in this particular 
case I felt the greatest anxiety, frequently stopping dur- 
ing the operation to ask Dr. Campbell if all was going 
on well with the patient. At the end of forty minutes 
the sutures (twelve or thirteen) were all placed, and 
ready to be secured, and I was secretly congratulating 
myself that the operation would be finished in a few 
minutes more, when all at once I discovered an unusual 
bluish-livid appearance of the vagina, as if the blood 
were stagnant, and I called Dr. Johnston's attention to 
it. As this lividity seemed to increase, I felt rather un- 
easy about it, and I asked Dr. Campbell if all was right 
with the pulse. He replied, " All right, go on." Scarcely 
were these words uttered, when he suddenly cried out, 
" Stop ! stop ! No pulse, no breathing ; " and, looking 
to M. Nelaton, he said, " Tete en bas, n'est-ce pas?" 
Nelaton replied, " Certainly ; there is nothing else to 
do." Immediately the body was inverted, the head 
hanging down, while the heels were raised high in the 
air by Dr. Johnston, the legs resting one on each of his 
shoulders. Dr. Campbell supported the thorax. Mr. 
Herbert was sent to an adjoining room for a spoon, with 
the handle of which the jaws were held open ; and I 
handed M. Nelaton a tenaculum, which he hooked into 
the tongue, and gave in charge to Mr. Herbert ; while to 
Dr. Bey lard was assigned the duty of making efforts at 
artificial respiration, by pressure alternately on the 
thorax and abdomen. M. Nelaton ordered and over- 
looked every movement, while I stood aloof and watched 
the proceedings with, of course, the most intense anx- 
iety. They held the patient in this inverted position for 
a long time before there was any manifestation of return- 

8* 



90 ARTIFICIAL ANAESTHESIA. 

ing life. Dr. Campbell, in his report, says it was fifteen 
minutes, and that it seemed an age. My notes of the 
case, written a few hours afterwards, make it twenty 
minutes. Be this as it may, the time was so long that I 
thought it useless to make any further efforts, and said, 
u Gentlemen, she is certainly dead, and you might as 
well let her alone." But the great and good Nelaton 
never lost hope, and by his quiet, cool, brave manner, he 
seemed to infuse his spirit into his aids. At last there 
was a feeble inspiration, and after a long time another, 
and b}- and by another; and then the breathing became 
pretty regular, and Dr. Campbell said, " The pulse re- 
turns, thank God! she will soon be all right again." 
Dr. Beylard, who always sees the cheerful side of every- 
thing in life, was disposed to laugh at the fear I mani- 
fested for the safety of our patient. I must confess that 
never before or since have I felt such a grave responsi- 
bility. When the pulse and respiration were well re- 
established, M. Nelaton ordered the patient to be laid on 
the table. This was done gently. But what was our 
horror, when, at the moment the body was placed hori- 
zontally, the pulse and breathing instantly ceased. Quick 
as thought the body was again inverted, the head down- 
ward and the feet over Dr. Johnston's shoulders, and 
the same manoeuvres as before were put into execution. 
Dr. Campbell thinks it did not take such a long time to 
re-establish the action of the lungs and heart as in the 
first instance. It may have lacked a few seconds of the 
time, but it seemed to me to be quite as long, for the 
same tedious, painful, protracted, and anxious efforts 
were made as before, and she seemed, if possible, more 
dead than before; but, thanks to the brave men who had 
her in charge, feeble signs of returning life eventually 
made their appearance. Respiration was at first irregu- 
lar, and at long intervals ; soon it became more regular, 
and the pulse could then be counted, but it was very 
feeble, and would intermit. I began again to be hopeful, 
and even dared to think that at last there was an end 
of this dreadful suspense, when they laid her horizon- 
tally on the table again, saying, " She is all right this 
time." To witness two such painful scenes of danger 
to a young and valuable life, and to experience such 



RESUSCITATION FROM CHLOROFORM NARCOSIS. 91 

agony of anxiety, produced a tension of heart, and 
mind, and soul that cannot be imagined. What, then, 
must have been our dismay, our feeling of despair, when, 
incredible as it may seem, the moment the body was laid 
in the horizontal position again, the respiration ceased 
a third time, the pulse was gone, and she looked the per- 
fect picture of death ? Then I gave up all for lost ; for 
I thought that the blood was so poisoned, so charged 
with chloroform, that it was no longer able to sustain 
life. But Nelaton, and Campbell, and Johnston, and 
Be3'lard, and Herbert, by a consentaneous effort, quickly 
inverted the body a third time, thus throwing all the 
blood possible to the brain, and again they began their 
efforts at artificial respiration. It seemed to me that 
she would never breathe again ; but at last there was a 
spasmodic gasp, and, after a long while, there was an- 
other effort at inspiration ; and, after another long inter- 
val, there was a third ; they were "far between ;" then 
we watched, and waited, and wondered if there would 
be a fourth; at length it came, and more profoundly, 
and there was a long yawn, and the respiration became 
tolerably regular. Soon Dr. Beylard says, " I feel the 
pulse again, but it is very weak." Nelaton, after some 
moments, ejaculates, " The color of the tongue and lips 
is more natural." Campbell says, "The vomiting is 
favorable; see, she moves her hands; she is pushing 
against me." But I was by no means sure that these 
movements were not merely signs of the last death 
struggle ; and so I expressed myself. Presently, Dr. 
Johnston said, " See here, doctor; see how she kicks; 
she is coming round again;" and very soon they all said, 
" She is safe at last." I replied, " For heaven's sake, 
keep her safe ; I beg you not to put her on the table 
again until she is conscious." This was the first and 
only suggestion I made during all these anxious mo- 
ments, and it w r as acted upon ; for she was held in the 
vertical position till she, in a manner, recovered semi- 
consciousness, opened her eyes, looked wildly around, 
and asked what was the matter. She was then, and not 
till then, laid on the table, and all present felt quite as 
solemn and as thankful as I did; and we all in turn 



92 ARTIFICIAL ANAESTHESIA. 

grasped Nelaton's hand, and thanked him for having 
saved the life of this lovely woman. 

In a few minutes more the operation was finished, but, 
of course, without chloroform. The sutures were quickl3 r 
assorted and separately twisted, and the patient put to 
bed ; and on the eighth day thereafter I had the happi- 
ness to remove the sutures in the presence of M. Ne*la- 
ton, and show him the success of the operation. 

I have detailed the circumstances of this interesting 
case at great length, because I believe it goes as far to 
establish a principle of treatment as any one case ever 
did, or possibly can. 

Nitrite of Amyl as an Antidote to Chloroform. 

Within the last few 3 r ears the nitrite of amyl has as- 
sumed considerable importance as a remed}' in all spas- 
modic affections. The first notice of its effects was by 
Prof. Guthrie, who, while distilling nitrite of am}'! from 
amylic alcohol, observed that the vapor, when inhaled, 
quickened his circulation, and made him feel as if he had 
been running. There was flushing of his face, rapid 
action of the heart, and difficult breathing. In 1861—2, 
Dr. B. W. Richardson, of London, made a careful and 
prolonged study of the action of this singular body, and 
discovered that it produced its effect by causing an ex- 
treme relaxation, first of the bloodvessels, and afterwards 
of the muscular fibres of the bod}\ To such an extent 
did this agent relax that it would even overcome the 
tetanic spasm produced by stiychnia, and relieve the 
most agonizing of known human maladies — angina pec- 
toris. Even tetanus has been subdued by it in two in- 
stances. In asthma, m}- own experience coincides with 
that of others that it will, in certain spasmodic forms, 
instantly arrest the paroxysm. An exceedingly conve- 
nient mode of carrying the drug was by means of thin 
glass globules of nitrite of amyl, containing respectively 
TT^iiss and n^v, suggested by Hubbell, of this city. 
When required, one of the bulbs is broken in a hand- 
kerchief or towel, and its contents immediately inhaled. 
I have employed this agent in spasmodic ear cough, also 
in tinnitus aurium, in which there is spasm of the mus- 



NITRITE OF AMYL AND CHLOROFORM. 93 

cles of the ear bones, in which case I directed the patient 
to cany a small glass-stoppered bottle, and to inhale five 
or six drops on a handkerchief, or even hold the nose for 
a second to the month of the bottle containing a small 
quantity. 

At times T have been very much disappointed in the 
effects, and on examination of the drug, even obtained 
from a first-class store, it was found to be amylic ether, 
and not nitrite of amyl. Dr. Burrall, of New York, has 
recapitulated the experiments performed upon cats and 
dogs by others and himself, and set the amyl down as an 
agent which should always be in the armamentarium of 
the medical man who went prepared to meet any emer- 
gency that might arise while producing anaesthesia with 
chloroform. 

Dr. W. L. Lane has repeated numerous experiments 
on animals with the nitrite of amyl, and states, "When 
inhaled in small quantities it produces recovery from 
chloroform insensibility (see experiments, British Med. 
Journal, Jan. 7, 1877) by dilating the arterioles of the 
brain, and thus removing the cerebral anaemia due to the 
chloroform. It also helps to produce recovery from 
the chloroform insensibility by raising the temperature, 
which is always lowered by chloroform, and by remov- 
ing the paralysis of the heart due to chloroform ; this 
action is well seen by the nitrite of amyl making the 
heart's beats fewer and sounds louder. This action of 
the nitrite of amyl in flushing of the face and eyes, caus- 
ing increased heat, and making the heart beat slower, but 
with an irregular action, we have experienced in our own 
person in doses of two mimims and a half by inhalation." 

Dr. Lane also states by way of caution, that, where the 
pure nitrite of amyl is inhaled in large quantities, in- 
stead of producing recovery from chloroformic insensi- 
bility, it not only retards it, but it may cause death by 
paralysis and over-distension of the heart and engorge- 
ment of the venous system. In large doses (inhaled), 
it produces a fall of temperature. 



94 ARTIFICIAL ANESTHESIA. 

The Influence of Nitrite of Amyl in Counter- 
acting the Depressing Effects of Ether and 
Chloroform during Anaesthesia. 

Dr. Munde (in Am. Journal Medical Sciences, Jan. 4, 
1878) states : " The beneficial effects of nitrite of amyl in 
stimulating the heart, and thus permitting the continued 
administration of ether (in an operation for ovariotomy), 
were witnessed by all the pli3 T sicians present, and are un- 
questionable. He also states that two cases of resusci- 
tation from chloroform S3*ncope by amyl-nitrite have 
been reported by Dr. Pilcher in his report on croup and 
diphtheria; and very recently* 1 find a case published 
in which the inhalation of the nitrite of amyl, which for- 
tunately was at hand, according to the testimony of 
physicians present, revived the patient from sudden 
chloroform collapse, and saved her life." 

Nitrite of Amyl in Threatened Death from 
Chloroform. 

The Editor of the British Medical Journal says: We 
have received the following interesting report for pub- 
lication from a physician: — 

M On the 9th instant I was asked by a professional friend 
to administer chloroform to a patient of his, from whom 
he was about to remove a fatty tumor situated in the left 
lumbar region. The patient in question was about fort3'- 
nine years of age, married, the mother of several children ; 
of thin, spare habit, but otherwise in good health. She 
was nervous, and apprehensive of the result, entreating 
me not to give her too much chloroform. Having pre- 
viously examined the heart and found all sounds normal, 
I gave her about two tcaspoonsful of brandy undiluted, 
and after waiting a few minutes, and placing her in a 
recumbent posture, I commenced the administration. 
The chloroform I used was Duncan & Flockhart's, upon 
the purity of which we can always depend. I poured a 
measured drachm upon a piece of lint enveloped in a 

* British Med. Journal, August 18, 1877. 



THREATENED DEATH FROM CHLOROFORM. 95 

towel. I held it some little distance from her month 
and nose, and let her inhale slowly. My friend noted 
her pulse, whilst I carefully watched the respiration. 
The first dose did not produce any effect, and I then used 
another drachm, which soon caused a good deal of ex- 
citement, incoherent talking, and struggling, the patient 
striving several times to snatch the inhaler from my 
hand. This gradually subsided, and she appeared to be 
passing into the third stage of anaesthesia, when she made 
an abortive attempt to vomit, raised her head from the 
pillow, and, to my friend's great alarm, the pulse flickered 
and stopped altogether ; she gave a gasp ; foam gath- 
ered on her lips; her jaw became rigid, and to all ap- 
pearance she was dead. I immediately withdrew the 
chloroform, my friend dashed some cold water in her 
face and pulled her tongue forward, whilst I commenced 
artificial respiration, after Marshall Hall's method, but 
without success. We then poured some nitrite of amyl 
on lint and held it to her nostrils. In such emergencies 
it is impossible to judge the flight of time correctly, but 
I should say in ten seconds there was a flushing of the 
face, the pulse was again felt, and, to our great jo} r , the 
all important function of respiration was again restored, 
the woman being rescued apparently from the very em- 
brace of death." 

J. T. Clover, Esq., in a note to the writer dated Lon- 
don, Dec. 20, 18*75, in answer to a query in regard to 
chloroform and his " bag apparatus," writes, " I beg 
to sa} T that m} T opinion of chloroform and of the bag ap- 
paratus for administering chloroform has not altered 
since the publication of the late Dr. Sansom's book." 

In another published statement this same good au- 
thority writes:* " For giving chloroform, with or without 
ether, I use a modification of my bellows and bag ap- 
paratus. The favorable opinion as to the greater safety 
of ether, and the increased alarm as to chloroform, to- 
gether with the improvements in the way of giving ether, 
have induced me within the last four or five years to 
give ether much oftener than chloroform." 

• * British Med. Journal. 



96 ARTIFICIAL ANAESTHESIA. 

Mixed Narcosis. — "During the past two or three 
weeks," sa}*s the Lancet, December 1, a " novel mode of 
producing anaesthesia, called mixed narcosis (gemischte 
narkose), has been employed by Thiersch, of Leipzig, 
whereby insensibility to pain may be procured without 
the total abolition of consciousness. The credit of the 
discovery is ascribed to Professor Nussbaum, of Munich. 
Although suitable for all kinds of operations, it is espe- 
cially serviceable for operations about the mouth and 
jaws, in which blood is apt to flow into the trachea, or 
down the oesophagus into the stomach, and subsequently 
to cause vomiting. In some cases of removal of the 
upper jaw lately performed by Thiersch, the patient 
allowed the blood to accumulate for a while at the back 
of the pharynx, and then spat it completely out, when 
asked to do so ; and we are informed that in one in- 
stance the patient watched, with evident interest, the 
motion of the saw that was dividing his upper jaw-bone. 

" A subcutaneous injection of morphia, from a quarter 
to half a grain, is given as soon as the patient is placed 
upon the operating table, and immediately afterward the 
administration of chloroform is commenced. After in- 
halation for about five minutes the operation may usually 
be begun, but the chloroform must be renewed at inter- 
vals. The patients lose all sensibility to pain, but evi- 
dently retain a considerable degree of consciousness and 
control of voluntary movements. Within the last month 
mixed narcosis lias been employed five times sucessfull}', 
as far as the annihilation of pain is concerned, and with- 
out any bad effects." 

The dose of morphia which is given in the communi- 
cation in the Lancet is too large for safety, as there are 
many persons on whom even one-quarter of a grain of 
morphia hypodermically will act as a powerful poison, 
while half a grain even produces death. The injection of 
morphia should be small, say from one-eighth to one- 
quarter, and this should be given, according to Claude 
Bernard, from forty minutes to one hour before the chlo- 
roform is employed. The question should always be 
put to the patient, have you ever employed morphia? 
And, if so, what effect has it upon you?- The great ad- 
vantage claimed for this method is that the stage of ex- 



DEATHS FROM CHLOROFORM. 97 

citement is rendered alwaj'S nil, and less chloroform is 
needed to induce sleep than under ordinary circumstan- 
ces. It must always be borne in mind that nausea and 
vomiting are not uncommon at the commencement if the 
morphia is quickly absorbed. This, with the vomiting 
which accompanies chloroform, will, we fear, be apt to 
complicate a delicate operation, and then you have the 
double risk of two such poisonous agents. 

Deaths from Chloroform. 

" The following account, with the post-mortem, is full 
and accurate.* On Friday, January 5, 187*7, a death fol- 
lowing the administration of chloroform occurred in the 
office of a dentist of Rah way, New Jersey. Walter E. 
Lewis, a lad, aged 14 years, shortly after taking a hearty 
supper, stopped, in company with a younger brother, at 
the office of a dentist in that place for the purpose of 
having a tooth extracted. He was accordingly seated 
in the operating chair, and the administration of the 
anaesthetic commenced without delay. An ordinary 
folded napkin was placed over his nose and mouth, and 
he instructed to take forced and deep inspirations. After 
several of these had been taken, and a slight struggling 
had been controlled, the tooth was extracted, immedi- 
ately after which there was a gasp for breath, a deep 
sigh, and the head of the boy rolled to one side, and he 
was dead. The dentist, in alarm, left the boy in a sit- 
ting posture and ran for help. The nearest available 
help was Dr. Daly, but he being absent, Mr. Marsh, a 
student of his, answered the summons, and repaired to 
the place with a galvanic battery. It was not until his 
arrival, a period estimated at a quarter of an hour, that 
the deceased was placed in a recumbent posture upon 
the floor and any efforts made at resuscitation. Dr. 
Sclover arrived shorUy afterwards, resorted at once to 
artificial respiration, applied the galvanic battery, and 
administered hypodermic injections of ammonia, but all 
to no purpose. At the time he saw the child the pulse 
had ceased to beat. 

* Medical Record, January 7, 1877. 



y» ARTIFICIAL ANAESTHESIA. 

"An autopsy was held Jan. 8th, at the instance of the 
county physician, Dr. F. B. Gellette, of Plainfield, N. J., 
assisted by four physicians. The body was spare, but 
well nourished, cadaveric rigidity marked. On removing 
the coverings of the chest the muscles were found to be 
of a darker hue than normal. The pericardial sac con- 
tained a slight excess of straw-colored serum. The heart 
was normal in size, the right ventricle showing the usual 
amount of adipose tissue upon its surface. The vessels 
of the heart were ligatured previous to removal, and on 
being severed a quantity of dark blood escaped. The 
right ventricle was flaccid, and contained about half an 
ounce of the same character of blood noted above. The 
left ventricle was quite firmly contracted, and was en- 
tirety empt}'. No thrombi were found. All the valves 
of the heart were sufficient, and the muscular substance, 
on microscopical examination, was found to be free from 
fatty degeneration. The liver was of normal size, but 
congested throughout, and both lungs were in the same 
condition, slightly crepitant on pressure, and discharg- 
ing from the cut surface of the smaller tubes a frothy 
mucus. 

14 The stomach was filled with a full and but partially 
digested meal, a portion of which found its way into the 
oesophagus by post-mortem gravitation. The mucous 
membrane of the organ was apparently healthy, and 
showed no evidence of post-mortem digestion. The 
larynx and trachea were entirely free, as was also the 
fauces, which fact destroyed the probability of choking 
during any possible effort at vomiting. Both passages 
were, however, markedly injected with venous blood ; 
the same was the case with the small intestines and kid- 
neys, which otherwise presented a healthy appearance. 
The bladder was half full of urine. The peritoneum, 
except a slight congestion, was also normal. 

"The brain was carefully examined. Its substance 
appeared normal. Its surface shared in the general 
venous congestion to a slight extent. No abnormal 
amount of fluid was found in the ventricles." 

"With the recent Rahway tragedy still fresh in our 
minds, we are called upon to record another victim to 
the administration of chloroform, whilst in a dentist's 



DEATHS PROM CHLOROFORM. 99 

chair. In this instance the case was that of the wife of 
a prominent citizen of Rock Island, Iowa. As far as we 
can learn from the report furnished us, every precaution, 
save allowing the patient to sit in the chair, was taken 
to guard against the accident. The gentlemen who ad- 
ministered the anaesthetic was an experienced physician, 
and had performed a similar service to the patient be- 
fore. Death appeared to be instantaneous from paralysis 
of the heart. If it were necessary to prove the danger- 
ous character of chloroform as an anaesthetic in dentistry, 
we could hardly select a more direct case in point than 
the one under consideration. In the Rahway case the 
patient had a full stomach at the time of the accident, 
and there were other circumstances which more or less 
directly invited the issue; but in the Rock Island case 
there would seem to have been every chance for escape, 
except for the fact that the chloroform was given for 
tooth drawing, and the patient was at the time in the 
dentist's chair. In this connection we must refer to still 
another death from chloroform, occurring as an accom- 
paniment of an equally trifling operation." 

u We regret to have to record a death from chloro- 
form, which occurred last week at University College 
Hospital, and, as has been frequently noticed in other 
instances, it occurred during only a trifling operation. 
We are indebted for the details to one of the house- 
physicians. The man was sent up to the ward from the 
out-patient room about four P. M., for the removal of a 
piece of carious bone from the stump of an arm. He 
was placed lying on a bed, with loosened dress, and as 
he felt pain very acutely, chloroform was ordered ; it 
was not measured, but from one to two drachms were 
poured on lint, and afterwards the administration was 
continued guttatim. After a good deal of struggling he 
became suddenly under the influence, and the operation 
was commenced. He breathed equably for a few seconds, 
but when Mr. Heath grasped the bone, the breathing 
suddenly stopped. The pulse seems to have ceased 
about the same time. He is said to have been of rather 
dark complexion, and the administrator did not notice 
any marked change of color, though others thought it 
became bluish. Artificial respiration by Silvester's 



100 ARTIFICIAL ANESTHESIA. 

method was the principal remedy adopted, and energeti- 
cally applied about half an hour, but to no purpose; 
brandy was not given. On the supposition that possibly 
some substance was fixed in the larynx, Mr. Heath per- 
formed laryngotomy as a last resource. At the post- 
mortem examination, the heart-substance was found in a 
state of marked fatty degeneration. We may say that 
the man's age was thirty-seven, and not twenty-eight, as 
stated in the newspaper reports. We have no clear his- 
tory of his habits. He had taken ether safely at a pre- 
vious operation. At the inquest, Dr. Crocker stated 
that the death occurred from misadventure, and the jury 
returned a verdict to that effect."* 

If these and similar experiences serve as nothing more 
than new and forcible illustrations of old and acknow- 
ledged facts, a particular reference to them will not be 
in vain. 

" Dr. Charles A. Jourdan, a dentist, was put under the 
influence of chloroform for the purpose of having the 
left eye extirpated, which had received an injury five 
months previously while he was living in Texas. 

" The patient was placed on the operating table, and 
chloroform was administered in the usual way, which 
soon brought on that sleep that knew no wakening; the 
eye was speedily removed, when the pulse and breath 
simultaneously ceased, and all efforts to resuscitate were 
unavailing; he never breathed after the first alarming 
symptoms were noticed. He had a good constitution 
and no organic disease of any kind, which was proven 
by post-mortem examination."f 

A death during the inhalation of chloroform, prepara- 
tory to undergoing an operation, has occurred in a vil- 
lage near Llanelly, South Wales. The patient, a collier, 
twenty-nine years of age, in fairly good health, suffered 
from fistula in ano, for which Messrs. Buckley and 
Thomas, surgeons, determined to operate. After inhal- 
ing the anesthetic for a few minutes, the patient became 
suddenly blanched in the face, and breathed feebl}', and 
in spite of the endeavors of the surgeons, who perse- 

* British Medical Journal, January 20, 1877. 

f American Journal of Dental Science, May, 1877. 



DEATHS FROM CHLOROFORM. 101 

vered for an hour in performing artificial respiration, 
died. The autopsy revealed a hypertrophied condition 
of the heart, and at the subsequent inquest the jury re- 
turned a verdict of " accidental death during the admin- 
istration of chloroform."* 

Dr. Tayloi't states that u Fatal cases have been pro- 
portionally much more numerous from the use of chlo- 
roform vapor than from ether vapor. In one case, 
witnessed by a friend of Dr. Taylor's, the heart suddenly 
ceased to beat four minutes after the vapor had been 
withdrawn. The digital arteries, which had been divided 
in the surgical operation, ceased to beat. The man was 
dead. Two fatal cases are reported in the Brit. Med. 
Journ. for August, 1873, p. 230. In one, a man, in good 
general health, died suddenly after having inhaled one 
drachm of chloroform in vapor. Fatal syncope came on 
after the chloroform had been withdrawn. In the other 
case, a lady died at Brighton under the influence of 
chloroform, while having a tooth extracted. In this 
case, it is said, there was fatty degeneration of the heart. 
It is to this condition of a fatty or flabby heart that the 
fatal effects are usually ascribed. Assuming this to be 
to some extent the true cause of the fatality, it must be 
admitted that fatty and flabby hearts have become ex- 
ceedingly common since the introduction of chloroform 
vapor for surgical and other purposes ! But this theory 
is not necessary to explain the fatal results. Tt^ are 
simply cases of poisoning. In January, 1866, a healthy 
man died in three minutes from the effects of two 
drachms of chloroform given in vapor. This death oc- 
curred on the operating-table of a London hospital; the 
vapor having been administered by a gentleman who 
had given it previously to 300 or 400 patients. Death 
was sudden, and took place after some deep inspirations 
and expirations had been made. It was on this occasion 
candidly admitted that the body was quite healthy. I 
have been unable to procure any reliable information re- 
specting the statistics of deaths from chloroform in 

* London Lancet, Dec. 8, 1877. 
f On Poisons, op. cit., p. 62. 
9* 



102 ARTIFICIAL ANESTHESIA. 

surgical operations. Hospital authorities are unwilling 
to place their fatal cases before the public." 

The London Lancet of February 10th, 187*7, records 
the death, in the Peterborough Infirmary, of a man fifty- 
two years of age. The patient was placed under the 
influence of chloroform (two drachms in all being used) 
for the reduction of a strangulated inguinal hernia. It 
is the old story. The pulse and respiration sud- 
denly ceased, and, although efforts at resuscitation were 
promptly employed, the man never rallied. 

The last case was that of a woman for whom ligature 
of the carotid was to be performed for an aneurism of 
the aorta. The patient suddenly ceased to breathe, 
when laryngotomy was performed. The left innominate 
vein, as was afterwards discovered, being occluded, some 
veins crossing the larynx were much dilated. These 
were unavoidably wounded in the operation, a quantity 
of blood entered the air-passages, and, although it was 
promptly sucked out, the delay was fatal. The patient 
had taken but little chloroform when the obstruction to 
respiration occurred. In neither case is there any re- 
port of a post-mortem examination. 

"A case of death whilst under the influence of chloro- 
form recently took place at the Derby Infirmary. 
Deceased, who was fifty-six years of age, was about to 
undergo an operation for fistula and haemorrhoids ; but 
before he was ready for operation, the respiration sud- 
denlj r became very irregular, he struggled violently, and 
the pulse, which had up to this time been good, ceased. 
In spite of all the means resorted to for a considerable 
time, he showed no signs of rallying from the first. The 
quantity of chloroform which had been poured into the 
lint-holder was in all about three drachms. The post- 
mortem examination did not reveal any organic dis- 
ease."* 

Another case, the patient being a boy, aged eight, is 
recorded in the same journal for November 11, 1876. 

14 Dr. Gustav Judell, privat-docent and chemical as- 
sistant in Professor Leube's clinic at Erlangen, was, on 
October 2Gth, found dead in his bed. He had been ac- 

* Brit. Med. Journ., March 17, 1877. 



DEATHS FROM CHLOROFORM. 103 

customed to take chloroform at night as a remedy for 
sleeplessness, by which he was much troubled ; and a 
bottle containing the anaesthetic was found near him. 
It appears that vomiting was excited by the chloroform, 
but that he was too deeply narcotized to eject the con- 
tents of the stomach, so that portions of the food 
remained in the oesophagus and caused death, by suffo- 
cation."* 

In the month of February, 1878, a Miss Wilson died 
in a dentist's chair in Brooklyn, after the extraction of 
ten teeth under the influence of two doses of chloroform. 
The coroner's jury, in summing up the evidence, gave 
as its opinion, that the hapless woman died from as- 
phyxia, caused by the use of chloroform, and they con- 
demned the use of anaesthetics in dental operations. 
We do not wonder that dentists who are not always 
familiar with the number of fatal cases of death from 
the inhalation of chloroform employ it, when they see it 
recommended by some of the most distinguished sur- 
geons of the land, in the face of the almost constant 
deaths from its direct influence. These latter are the 
culpable ones, for they sin against the knowledge of its 
fatal character. If no other anaesthetic could be found 
there might be some reason for their wilful misrepre- 
sentations. Where ether and nitrous oxide can be had 
almost perfectly safe, why should such a dangerous 
agent be recommended ? 

The subjoined abstract of remarks by the editor of 
the Brooklyn Eagle, shows the popular impression in 
regard to the use of chloroform : — 

14 The obvious reason why, in the opinion of this jury, 
anaesthetics should not be administered 4 in such opera- 
tions,' can have no possible reference to the operations 
themselves. Tooth-pulling is an art of easy attainment 
by any human being of stout nerves and moderately 
powerful wrists, and in the simplicity of the operation 
lies its principal peril. Since an} r fool can extract teeth, 
a great many fools do, and the law requiring no special 
education of dentists in the study of physiology, the 
profession is overrun with quacks. Since the introduc- 

* Med. Examiner, November 18, 1877. 



104 ARTIFICIAL ANAESTHESIA. 

tion of anaesthetics into dental operations, every quack 
finds himself called upon to administer the soothing 
drug to a patient, and, without any knowledge of the 
human frame, he does it — frequently with fatal effects. 
What does he know of the effects of anaesthetics ? What 
theory can he possibly have of their action ? What does 
he know of ganglia and their lesions, which render the 
administration of chloroform to some patients certain 
death from paralysis of the pneumogastric nerve ? All 
he knows is that some dentists give their patients a drug 
which deprives them of consciousness, and therefore of 
pain. Chloroform is the best known of these drugs, and 
since no embargo is laid upon its miscellaneous sale, it 
is easily procurable. Like all articles of merchandise, 
it has its grades. Good, pure chloroform is at best a 
hazardous anaesthetic, which should be employed with 
the utmost caution, while the inferior quality may be 
regarded as usually fatal in effect. This opinion pre- 
vails among scientific men who have made a study of it. 
The dentist — a retired farmer, a discharged dry goods 
clerk, or a politician out of office — knows nothing of 
this, however, and goes on administering chloroform 
without hesitation. Ether, on the other hand, is a com- 
paratively safe agent, and competent dentists prefer its 
use to that of chloroform. Of ether and nitrous oxide, 
and other mitigating drugs, the quack dentist is as ig- 
norant as could be expected, and hence he cleaves to his 
fatal chloroform; comes before a coroner's jury every 
now and again, with blanched cheeks and a general air 
of perplexity, until habit accustoms him to the office of 
executing his fellow creatures without surprise or re- 
morse. 

" Since the operations of dentistry are extremely pain- 
ful, it would appear that they offer to the beneficent 
discoveries of science in banishing pain a most fruitful 
field, but inasmuch as the avoidance of fatal conse- 
quences from the use of anaesthetics depends upon the 
knowledge of the practitioner, it would appear to be a 
matter of some importance that the dentist should be a 
person of education in at least this particular branch of 
physiology. He should, at all events, understand the 
conditions under which his practice may become danger- 



DEATH PROM CHLOROFORM. 105 

ous to life or health, and to show that he does so under- 
stand, he should be called upon to exhibit a diploma. 
In other words, dentistry having advanced to a science, 
none but scientific practitioners should be allowed to 
perform its duties. It was all very well for the barber 
of a century ago to pull out the teeth of his patrons, 
or write their prescriptions, open their veins, and other- 
wise contribute to their general happiness and enjoy- 
ment of life, but we have left those days behind, and the 
good of the community demands that important trusts 
be confided only to those who are capable of discharg- 
ing them." 

Experimentation on Death from Chloroform. 

The first series of experiments I remember to have 
made were commenced in the years 1850 and 1851, and 
had reference to the mode and cause of death under 
chloroform. At the time named chloroform had been 
in use a little over two years for preventing the pain of 
surgical operations, and already nineteen deaths in man 
had occurred from it. 

These calamities had produced very painful and anx- 
ious feelings amongst medical men, and my researches 
had for their intention the elucidation of many points 
of practical importance. The mode of procedure was 
to narcotize the animals, with various degrees of rapidity, 
with varying percentages of chloroform vapor in the at- 
mosphere, and during various atmospherical conditions ; 
to note carefully the phenomena produced on the heart 
and on the respiration, and the duration of the four 
stages of narcotism. In some instances the animals — 
rabbits were usually subjected to experiment — were al- 
lowed to recover ; in other instances the narcotism was 
continued to death. When the narcotism was made to 
be fatal the immediate cause of death was noted, and 
the body left until the" rigidity of death could be re- 
corded. Then all the organs were carefully inspected, 
in order to see what was the condition of the lungs, the 
heart, the brain, the spinal cord. 

The results obtained by these inquiries were of direct 
practical value. By them I showed in various lectures 
and papers the following major facts : — 



106 ARTIFICIAL ANAESTHESIA. 

1. That the cause of the fatalit}' from chloroform does 
not occur, as was at first supposed, from au} r particular 
mode of administration of the narcotic. 

2. That chloroform will kill, in some instances, when 
the subject killed by it exhibits, previous to administra- 
tion, no trace of disease or other sign by which the 
danger of death can be foretold. 

3. That the condition of the air at the time of ad- 
ministration materially influences the action of the nar- 
cotic vapor. That the danger of administration is much 
less when the air is free of water vapor, and the tem- 
perature is above 60°, but below 70°, Fahr. 

4. That there are four distinct modes of death from 
chloroform, and that when the phenomena of death 
from its application appear, the}' are infinitely more 
likely to pass into irrevocable death than from some 
other narcotics that may be used in lieu of chloroform. 

5. That all the members of the group of narcotic va- 
pors of the chlorine series, of which chloroform is the 
most prominent as a narcotic, are dangerous narcotics, 
and that chloroform ought to be replaced by some other 
agent equally practical in use and less fatal. 

6. That so long as it continues to be used there will 
always be a certain distinct mortality arising from 
chloroform, and that no human skill in applying it can 
divest it of its dangers. 

That knowledge of this kind respecting an agent 
which destroys one person out of every two thousand 
five hundred who inhale it was calculated to be useful, 
no reasonable mind, I think, can doubt. To me, who, 
many hundred times in my life, have had the solemn 
responsibility of administering chloroform to my fellow- 
men, it was of so much value that I should have felt it 
a crime if I had gone blindly on using so potent an in- 
strument without obtaining such knowledge. — Benjamin 
W. Richardson, in "Nature." 

Conclusions in Reference to the Use of 
Chloroform. 

In what class of cases can chloroform be employed with 
safety ? In my own experience, and after my experiments, 



USE OP CHLOROFORM. 107 

I would limit the use of this most potent of all the anaes- 
thetics to very young children who are weak, strumous, 
or overgrown. To puerperal eclampsia, in very violent 
convulsions, in male adults, or in females during deliv- 
ery, where rapidity of dilatation of the os uteri is abso- 
lutely necessary to save the mother's life. 

In some rare cases of painful operation, where, after 
continued efforts, no complete insensibility can be pro- 
duced b}^ ether, 1 would feel justified in the use of a por- 
tion of chloroform on a clean sponge or inhaler. In a 
certain class of inebriates, no amount of ether will be 
of much use in reducing a severe dislocation at the hip 
or shoulder-joint. In those cases accustomed to the free 
use of stimulants, chloroform may always be resorted to, 
using all the usual precautions. By a reference to the 
recent cases of deaths from this agent, I am fully satis- 
fied that no amount of care or precaution, or mode of 
administration, or amount inhaled, will prevent, in certain 
cases, the fatal result, and yet physicians and others will 
resort to the use of chloroform on account of its pleas- 
ant taste and odor, rapidity of action, cost, and compara- 
tive bulk. I have given its advocates every opportunity 
to state where, when, and how it can be given with safety, 
omitting nothing through prejudice or favor, having in 
my practice resorted to its use before being aware of the 
great risk incurred to every patient. 

In a recent pamphlet,* by an ophthalmic surgeon, Dr. 
Chisholm, of Baltimore, he advocates the exclusive use of 
chloroform as the "Ansesthetie," and considers ether un- 
satisfactorj', on account of the great distress occasioned 
by its forced inhalation in a concentrated form, its offen- 
sive odor, tiie large amount required, the excessive nausea 
induced, and the irritable cough often excjted ; and yet 
why will distinguished surgeons, like Drs. Jos. and Wm. 
H. Pancoast, Agnew, Ashhurst, Brinton, Morton, Allis, 
Levis, and others, give chloroform up on account of the 
greater safety to patients, and resort to the use of ether, 
some of them after years of its careful administration ? 
At the Pennsylvania, Episcopal, University, Jefferson, 

* What Anaesthetic shall we Use ? By J. J. Chisholm, M .D. 
pp. 23. Baltimore, 1877. 



108 ARTIFICIAL ANAESTHESIA. 

with the exception of Prof. Gross, Presbyterian, St. 
Joseph's, St. Mary's, German, and Jewish Hospitals, of 
Philadelphia, chloroform is not used but in rare cases, 
ether almost exclusively. 

The following are given b}^ Dr. Chisholm as his proofs 
of the safety of chloroform: "At the Edinburgh Infirm- 
ary, during a period of twenty-eight years from the in- 
troduction into surgical practice to the present time, 
only two deaths have been attributed to chloroform, 
which, according to Ker, is one death in 36,500 adminis- 
trations." Grant, in his admirable Treatise on Surgery, 
says : u I have seen chloroform given in some thousands 
of cases during upwards of twenty years, both in hospi- 
tal and private practice, without a single death, or even 
an approach to a fatal termination." Elser, of Stras- 
burg, had used chloroform 16,000 times, and had never 
seen a fatal case. Kidd, of London, had seen it adminis- 
tered upward of 10,000 times, and had seen no fatal case, 
either in his own practice or that of his friends. The 
French surgeons in the Crimea reported 30,000 cases of 
chloroform administered, and not one fatal issue. In 
the English army in the Crimea, chloroform was adminis- 
tered 12,000 times, with one single death reported as 
attributed to it. In the Confederate service, chloroform 
was exclusively used in a great many thousand opera- 
tions without a death, as far as I am aware of, or have 
been able to ascertain after diligent inquiry among lead- 
ing surgeons of the army. Surgeon McGuire, of Jack- 
son's Corps, reported 18,000 administrations without one 
death. Richardson had seen it used in the London hos- 
pitals 15,000 times before he met with the first fatal case. 
Bilroth, of Vienna, had administered chloroform 2500 
times before hq met with his first accident. Clover has 
recorded 3000 administrations without a single death. 
Erichsen has only witnessed one single death under 
chloroform in twenty-five years, at University Hospital. 
No official statistics, that I am aware of, have been pub- 
lished of the use of chloroform in the Federal army, nor 
in the recent wars of the French, German, and Austrian 
empires. 

Dr. J. Mason Warren, in 186*7, published his Surgical 
Observations, with cases and operations, in which he 



THE USE OF CHLOROFORM. 109 

mentions that in the Federal array chloroform was 
almost exclusively used in field operations. "The re- 
turns indicate that it was administered in no less than 
80,000 cases. In 7 cases, fatal results had been ascribed 
with apparent fairness to its use, a proportion of 1 
death in 11,428 administrations. Enough," he states, 
"has been already said, however, to prove that, under 
careful administration, deaths from chloroform must be 
among the rarest of accidents — so rare that it should 
not be seriously considered. 

To the testimon}' above I will add m} 1 - own individual 
experience. I have been practising surgery twenty-five 
years, and have used chloroform largely during that en- 
tire period, in private and hospital practice, in the army 
as well as in civil life, and have administered it to the 
extent of fully 6000 cases. Now let us sum up the evi- 
dence which Lhave collected, and here we find an array of 
over 250,000 administrations of chloroform with 12 
deaths ; even attributing them all to idiosyncrasy, which 
calls for a most unbounded charity, and we only have 1 
death in 20,000 cases. Can any stronger proof," he ob- 
serves, " of the excessive rarity of the fatal idiosyn- 
crasy in chloroform be needed ?" 

Now, on the other hand, what do other reliable autho- 
rities state, without going into much detail ? There have 
been 210 deaths faithfully recorded and reported, with 
the additional ones in this work, from chloroform (see 
Medical News and Library, Philadelphia, 1869), and 
these mostly occurred in the hands of the most experi- 
enced surgeons, and many of them in large hospitals 
where every appliance was to be had, and all the known 
means employed to prevent death. Where are the large 
numbers of deaths unreported which, like fatal opera- 
tions in surgery, never see the light of day, and are there- 
fore of no use to the seeker after truth ? 

In the recent admirable work on surgery by Erich- 
sen,* he discussed the question, Do anaesthetics influ- 
ence the rate of mortality after operation ? and concludes 
by stating: "I am inclined to believe that the rate of 

* The Science and Art of Surgery, p. 42. Philadelphia: H, 
C. Lea, 1878. 
10 



110 ARTIFICIAL ANAESTHESIA. 

mortality has increased since the use of anaesthetics in 
operative surgery." Again, "I cannot but think that 
chloroform does exercise a noxious influence on the con- 
stitution, and does lessen the prospect of recovery in 
certain states of the system, more especially when the 
blood is in an unhealthy st'ate." He states the most 
dangerous condition in which to administer chloroform 
is that in which, in consequence of renal disease, the 
blood is loaded with urea ; in such cases epileptiform 
convulsions are readily induced. 

In 1856, Mr. Erichsen,* in a letter to Dr. S. D. Town- 
send, of Boston, said, that "when a patient was fully 
under the influence of chloroform he was on the verge 
of death." 

Prof. Frank H. Hamilton, of New York, says: "In 
nearly all my surgical operations I prefer ether to chloro- 
form." 

The following correspondence explains itself, and I 
regret reporting that this distinguished surgeon still 
gives his influence in favor of the most dangerous of 
anaesthetics. 

1502 Walnut St., Jan. 28, 18T8. 

Prof. S. D. Gross : 

Dear Doctor : Knowing from your works that yon advocated 
and employed chloroform as an anaesthetic for many years, and 
having been informed you had for good and sufficient reasons 
given up its use, will you oblige me by giving me in a few words 
your reasons for so doing, and allow me to publish them in a little 
work I am about to have issued, and to which I have devoted 
considerable attention during the last two years ? 

Yours truly, 

L. TURNBULL. 

S. E. cor. 11th and Walnut Sts., 

January 29, 1878. 
Dear Doctor Turnbull : There is not one word of truth in the 
report that has reached your ear to the effect that I have abandoned 
the use of chloroform ; on the contrary, I employ it nearly, if not 
quite, as frequently as ever. It is only in operations upon the 
mouth, and in elderly, dilapidated subjects, that I prefer ether, 
and even in them it is questionable whether it possesses any de- 



* Records of the Boston Society for Medical Improvement, vol. 
iii. p. 34. 



CHLOROFORM VERSUS ETHER. Ill 

cided advantage over chloroform. As a rule, ether is undoubt- 
edly the safer anaesthetic ; but, with proper care in its adminis- 
tration, harm will seldom, if ever, befall our patients in the use of 
chloroform. 

I am, dear Doctor, very truly, yours, 
Dr. Laurence Turnbull. S. D. GROSS. 



Chloroform versus Ether. 

Timothy Holmes, F.R C.S., Surgeon to St. George's 
Hospital, London, author and lecturer, prefers chloroform 
to ether for the purpose of producing relaxation in the 
reduction of hernia and dislocations. It is more speedy 
and effectual in its action than ether, and he considers 
the dangers no greater. The Boston Medical and Sur- 
gical Journal prefixes the statement of Mr. Holmes's 
views with "Anno Domini 1877 !" 

We are surprised at the use of chloroform by Mr. Holmes 
in hernia, as in the majorit}^ of cases the system of the 
patient is very much depressed, and requires the stimu- 
lation of ether as well as its relaxing effects. We do not 
object so much to the use of chloroform, as we have be- 
fore stated, in the reduction of severe dislocations, espe- 
cially in beer-drinking and intemperate cases ; and Dr. 
Frank H. Hamilton, of New York, states that more com- 
plete muscular paralysis is more quickly and certainly 
attained by chloroform than by ether. 

We cannot conclude this part of our subject in more 
emphatic language than by noting the following: An- 
other case of death from chloroform is recorded in the 
British Medical Journal for Feb. 2, 1878. 

Dr.Moses Gunn, the distinguished surgeon of Chicago, 
now uses ether exclusively, using his great influence in 
its favor. 



112 ARTIFICIAL ANAESTHESIA. 



CHAPTER V. 

Original observations nnd experiments with hydrate of chloral. Liebreich 
on the impurities of chloral in cakes, test of purity, etc. Experiments 
of Dr. John A. Campbell at Garland Asylum, Carlisle. On chloral as 
an anaesthetic in children, by Dr. Bouchut, of Paris. M. Couty, of 
Paris, on death from chloral. Prof. Ore, of Bordeaux, venous injec- 
tions of chloral. Dr. J. M. Fothergill, of London, on the great utility 
of strychnia in chloral poisoning. Case of death from the use of chloral, 
and post-mortem appearances. Drs. Taylor and Tuke's opinions upon 
the effects of the long-continued use of chloral. The use of chloral 
for a Jong period with no serious results. 

Hydrate of Chloral. 

This new and valuable sleep-promoter, which has been 
so recently introduced into practice, has already been 
employed in thousands of cases. 

Chloral conforms to all the tests of Drs. Liebreich and 
Richardson, being solid, of a white color ; taste pungent 
and disagreeable, like that of a stale melon and chlorine. 
It dissolves with some difficulty in cold water, more 
freely in hot water, but requiring equal parts, by weight, 
for a perfect solution; is unaffected by nitrate of silver, 
and is slightly clouded by a solution of permanganate of 
potash. Its physiological and therapeutical action has 
been tested upon man and frogs.* 

According to Liebreich, it is altogether impossible to 
purify cake chloral. Chloral in diy, transparent crys- 
tals alone is reliable, not in needles but in rhomboidal 
plates.*) Thus chloral hydrate which is not perfectly 
pure may sometimes be observed to become acid. This 
increase of acidity is not due to the decomposition of 
chloral hydrate itself, but to the decomposition of an ac- 
companying impurity (chloro-carbonic acid), which sets 

* Original Observations and Experiments with Hydrate of 
Chloral, by Laurence Turnbull, M.D. Medical and Surgical Re- 
porter, Aug. 24. 1872. and Aug. 31, 1872. 

f Prof. Maisch, of this city, says the shepe of the crystals is no 
proof as a test of the purity of hydrate of chloral, lb., March 
9, 1878. 



HYDRATE OP CHLORAL. 113 

free hydrochloric acid. When this occurs m the stom- 
ach it gives rise to great irritation, and when it occurs 
in the blood it causes great constitutional excitement. 

Owing to the excessive alkalinity of the blood in ty- 
phoid fever, ten grains of chloral hydrate will often suf- 
fice to produce hypnotic effects, while in the state of 
excitement of delirium tremens twenty to thirty grains 
are necessaiy ; by hj T podermic injection, fifteen grains. 

Impure chloral hydrate is apt to produce nervous ex- 
citement; which state of excitation overcomes the hyp- 
notic effects. Chloral lrydrate poisons by paralyzing the 
heart, and its effects are observable in retardation of the 
pulse and respiration. Hence Dr. Liebreich has been 
led to urge the use of strychnine in combating these 
effects. The results of his experiments* have been con- 
firmed by subsequent observers. 

Fir at Experiment. — To a large frog was administered 
hypodermically near the inner part of the thigh half a 
grain (gr. ss) of hydrate of chloral in twenty minims of 
distilled water (xx n^). 

Nine minutes after, the frog was examined. The res- 
piration was increased to twenty (20) a minute, but not 
the slightest narcotic result was perceived; skin cooler 
than natural. Waited thirty minutes, and again injected 
(gr. ss) one-half a grain. Soon after there was a droop- 
ing of the head, relaxation of the limbs, closing of eye- 
lids (but no alteration of pupil), followed by profound 
stupor. In the course of ten minutes this animal be- 
came quite rigid, in fact, cataleptic; for, when the limb 
was stretched out, it retained that position. There was 
no tactile sensibility, not even when pricked or cut. 
When the web of the foot was placed under the micro- 
scope, two hours after the second injection, the blood, 
of a dark-red color, was found in active movement. 
This was witnessed by my son, Mr. (now Dr.) Charles 
S. Turnbull, and Mr. (now Dr.) G. B. Dixon. At this 
time the animal seemed almost dead, and no movements 
of respiration could be seen. The only motion was a 
feeble one of the heart, confirming Liebreich's views that 

* Trans. Ac. Med., Berlin. 
10* 



114 ARTIFICIAL ANAESTHESIA. 

the heart is the last part that dies while under the influ- 
ence of hydrate of chloral. 

Experiment Second. — Another frog was treated in a 
similar manner, with one grain (gr. j) of l^drate of 
chloral in solution, but it passed rapidly into the death- 
like state. The heart's action was so feeble as not to be 
noticed. 

Experiment Third. — A third frog was treated with 
three-quarters of a grain of hydrate of chloral, and was 
then carried to a meeting of the Philadelphia County 
Medical Society, where it was exhibited to the members 
present, in the apparently dead condition; and yet there 
was a movement of the circulation under the microscope. 
On removing the sternum, one hour after, the heart was 
found acting slowly, but soon stopped; and on stimu- 
lating it by friction the heart would again act, as in all 
cold-blooded animals. 

It will be seen, by the above experiments, that there 
are three stages of the action of chloral on animals. First, 
soporific; second, sedative; third, relaxant. 

Second, deep sleep, with diminished sensibility, and 
cataleptic state, with rigidity. The third state is a sleep 
so profound that it looks like death ; and, unless altered, 
death supervenes. 

Experiment Fourth, which demonstrates the fact that 
in small or moderate doses, from 5ss to 3ji hydrate of 
chloral is not an anaesthetic, but is a hypnotic, or a pro- 
ducer of sleep. Lady, aged 45, suffering from gastric 
fever, with distressing nausea and vomiting, and diar- 
rhoea, but unable to sleep for several nights, even under 
the influence of the camphorated and simple tincture of 
opium, also Dover's powder (pulv. ipec. et opii, U. S. P.), 
by enemata. Dissolved gr. xx of hydrate of chloral in 
a wineglassful of sweetened water, wiiich was admin- 
istered at 8 P. M. There was considerable heat of skin ; 
pulse rapid and feeble. It was taken while in the recum- 
bent position, and, her stomach being empty, no sick- 
ness or disagreeable results followed. In half an hour 
she was sound asleep. 

At 12 P. M., pulse quiet and slow ; breathing so gentle 
as not to be noticed; when, feeling uneasy on account of 
the very quiet sleep, she was simply touched on the 



HYDRATE OF CHLORAL. J 15 

hand ; she at once awoke, inquiring u if we wanted to 
wake her?" She changed her position, and again went 
to sleep, and slept without interruption until 8 A. M. the 
following morning. 

Experiment Fifth. — Lady, aged 34 ; has had a tumor 
removed from the uterus, and some months since she 
began to suffer the most distressing pain, with swelling 
in the region of the right ovary. All the domestic re- 
medies, as mustard plasters, hot fomentations, with hops, 
etc., had been tried in vain, also the application of opium 
and chloroform, but without benefit, being unable to take 
either morphia, opium, or any of its preparations. She 
was directed gr. xx of the hydrate of chloral in water 
and syrup. This was taken in two doses, resulting nei- 
ther in sleep nor relief of pain. She was then directed 
thirty grains (gr. xxx), after taking which she had three 
hours of sleep, and by repeating the half-drachm doses 
she was entirely relieved of the pain, and was able to 
sleep without being disturbed by noises or touch. 

In this case the hydrate of chloral did not act as an 
anaesthetic until fifty grains (gr. 1) had been adminis- 
tered. 

Experiment Sixth. — Young married woman, aged 25, 
with typhoid fever; pregnant, and threatened with abor- 
tion at third month ; pulse 100 ; temperature of skin 
107°; dry, with petechial eruption on abdomen on four- 
teenth day ; unable to sleep ; had taken at various times 
Dover's powder, bromide of potassium, tincture of opium, 
morphia, etc., but with very unfavorable effects. Di- 
rected the hydrate of chloral in water and syrnp of orange 
flowers. The first night she took twenty grains (gr. xx), 
but it was rejected by the stomach, still she slept for a 
short period ; second night she had ten grains (gr. x), 
still rejected ; third night, five grains (gr. v), and slept 
longer than any night since she has had the fever; less 
fever; heat of skin reduced to 96°, and pulse 90. 

On the fourth night she aborted, and fcetus was dis- 
charged, softened ; lost considerable blood ; placenta 
retained. The os was plugged, and in the morning re- 
moved the plug; but the placenta did not all come away 
for several days ; convalescent at the end of the sixth 
week. The hydrate of chloral was employed from the 



116 ARTIFICIAL ANESTHESIA. 

10th of February until the 16th of March. There is no 
doubt that it hastened the recovery very materially, by 
reducing the temperature of the skin, allaying pain and 
nervous excitement, which kept up the fever. The point 
of importance that these cases teach is that small doses 
are to be employed with persons of feeble constitution, 
or where there has been loss of blood. It also proves 
that it reduces the temperature of the skin ; this fact we 
have since proven in numerous cases. 

Experiment Seventh. — A comparison between the 
effects of morphia and hydrate of chloral. Mrs. N., aged 
34, has suffered with paroxysm of intense pain in the 
hypochondriac region, with obstruction of the bowels, 
followed by inflammation of a diphtheritic character, 
evidenced by cast being discharged. The only means of 
relief was by the use, hypodermically, of from half a 
grain (gr. ^) to three-quarters of a grain (gr. f) of mor- 
phia, which, although it gave her almost instant relief, 
was invariably followed by much distress in her head, 
with nausea and vomiting. By the use of seventy grains 
of hydrate of chloral she was relieved of her pain, and 
slept; and the most agreeable feature about the effect 
was that she awoke from her slumbers without any of 
the unpleasant s3 T mptoms in the head and stomach. 

Experiment Eighth — Mrs. R. M., aged 30, suffering 
in like manner, was relieved by sixty grains (so that 60 
to 70 grains of chloral were about equal to half a grain of 
sulphate of morphia). 

Experiment Ninth. — Cases of gout and rheumatism 
are better treated by adding soda or potassa in conjunc- 
tion with chloral, or the bromide of potassium. Samuel 
H., aged 54, was exposed to a sudden change of tempe- 
rature of twenty degrees reduction, without being suitably 
clad, and was attacked with acute rheumatism of the 
limb and knee; he was directed an anodyne and a stimu- 
lating Liniment with Dover's powder (pulv. ipec. et opii 
9j), gr. xx, but without relief. A mixture was then 
ordered him of aromatic water and syrup, of fifteen 
grains of potassae bicarb., and thirty grains of hydrate 
of chloral ; he took but five such doses, when he was free 
from nervous excitement and pain, and finally slept. By 
its occasional use he had no return of the disease. 



HYDRATE OF CHLORAL. 117 

Experiment Tenth. — John H. B., aged 45, while suf- 
fering with acute gout in his hands and hip, was ordered 
three ten-grain doses of chloral in water and syrup, but 
as it cnused him so much excitement, the soda bicarb, 
was ordered with it to get rid of the soda salts in his 
joints. This had the desired effect, and by its use for 
ten nights all his acute symptoms disappeared ; only a 
certain amount of stiffness remained. 

Experiment Eleventh. — Men require, as a general rule, 
larger doses than women, and in brain difficulties bro- 
mide of sodium is an admirable addition. 

John H. N., aged 56, suffering from amaurosis from 
atrophy of the optic nerve, was exposed, and contracted 
bronchitis, and the inflammation passed along the Eusta- 
chian tube to the middle ear, causing otitis media, fol- 
lowed by intense pain. He was ordered thirty grains of 
hydrate of chloral, without relief; a second dose of the 
same quantity, with a drachm of bromide of sodium ; this 
relieved the pain, and gave him a quiet, good night, and 
he awoke, with a slight discharge from the ear, but free 
from pain. 

Experiment Twelfth. — Its value in diseases in little 
children. — We have tested it in three typical cases during 
the heat of the summer of 18*71, in little children suffering 
from restlessness and cholera infantum. In almost every 
instance the child was able to sleep without pain or dis- 
turbance of the brain, by the soothing hypnotic influence. 
The chloral was combined with an aromatic syrup ; also 
chalk, and a small portion of port wine or syrup of 
brandy (made by burning the strong brand} 7 with sugar). 
Our dose was, for a child of 12 months, one grain of hy- 
drate of chloral, half grain of prepared chalk, and half 
grain of powdered gum arabic in each tablespoonful ; 
also, some mint, aniseed, or cinnamon water, so as to 
disguise the disagreeable taste. The hydrate of chloral 
should be increased in the proportion of one grain for 
each year. 

Experiment Thirteenth. — Frank N., aged 21 }'ears, of 
strumous tubercular habit, laboring under an attack of 
congestion of the lungs, with the pleura involved, pain 
very intense, respiration hurried, temperature 104°; 
pulse 120; directed a blister and fifty grains (gr. 1) of 



118 ARTIFICIAL ANAESTHESIA. 

hydrate of chloral in two doses. His mother, in her de- 
sire to relieve him, gave it at one dose. The effect was 
good, and his sleep profound; skin so cool and clammy 
that she became alarmed and woke him suddenly; yet, 
when he was thus awakened, he was not confused, was 
able to answer all questions directed to him, and was 
entirely free from pain, with free expectoration, and 
breathing much relieved. 

Experiment Fourteenth. — It is a most valuable agent 
in severe affections of the nervous system. 

The mother of the above lad, aged 45, had a most se- 
vere shock to her nervous system, owing to the sudden 
and terrible loss of two of her boys, aged respectively 
10 and 11 years, by drowning, which was followed, in 
her case, by nervous fever, with delirium and insomnia, 
aud unwillingness to take a particle of food for twenty- 
four hours. By prescribing and administering equal parts 
of syrup of chloral and fluid extract of valerian (each 
3j), with beef essence as food, she finally obtained 
sleep and recovered her reason, and was ultimately re- 
stored to good health. This will partially account for 
the large dose she gave her son, having had such faith in 
it herself. But in all diseases of the heart and lungs great 
care must be employed to commence with small doses, 
or to combine the chloral with a small quantity of mor- 
phine or tincture of Indian hemp. 

Experiment Fourteenth. — Miss J. W., aged 18, with 
panophthalmitis and destruction of the eye; pain and 
distress were relieved by three thirt} r -grain doses of \\y- 
drate of chloral, and was able to sleep. 

J. W., aged 52, father of the above, had his right eye 
penetrated by a percussion cap July 4, 1871, and 
had been under the care of a homoeopathic physician for 
treatment before coming to the hospital. He was pale, 
nervous, and in great agony, with entire loss of vision. 
The ej'e was removed, and thirty-grain doses of hydrate 
of chloral kept him free from pain. The only other 
means emplo3'ed was the use of the ice-bag. It is very 
useful in some forms of eye diseases of a strumous or 
neuralgic character, associated with quiniae sulphas, but 
not in other forms. 



HYDRATE OP CHLORAL. 119 

Experiment Fifteenth Heat toxaemia, thermic fever. 

— G. C, aged 22, male, a resident of Mexico, while 
on a visit to Darby, July 18, 18*71, had to walk a mile 
and a half in the broiling sun; was overcome, and obliged 
to retire to the shade, and was unable to proceed. Since 
which time he has had constant pain in the head, with 
heat of skin and almost complete insomnia. Reasoning 
on the former experiments of the cooling influence of 
chloral, and its effects upon the nervous system, I or- 
dered him ten-grain doses every three hours, in water, 
with ice to his head. After using it six hours he was 
able to sleep four hours; arose and took some nourish- 
ment ; he was free from pain in his head, and his skin 
reduced to 90°. Took the chloral again at 11 P. M., and 
had a good, quiet sleep, until 7 A.M. 

In some few instances the chloral will disturb and 
distress the stomach, sa} 7 in about three per cent, of the 
cases; but if incorporated with a portion of mucilage, it 
is rapidly absorbed. If given by the rectum, at the rate 
of double the quantity required by the mouth, it will in 
some instances produce swelling of the eyelids, and even 
cause intoxication and dimness of vision. 

In cases of chorea, epilepsy, and convulsions, arising 
from irritated nerves or reflex spinal irritation, it can 
be given with advantage alone, or in combination with 
the bromide of potassium or tincture of hyoscyamus. 
In acute mania, simple or puerperal, it is more valuable 
than Indian hemp, or bromide of potassium, or morphia, 
as numerous cases have demonstrated. 

Experiment Sixteenth. — Case of acute mania treated 
by cold, sedatives, morphia, etc., without inducing sleep, 
accomplished by the use of hydrate of chloral. Mrs. 
Letitia B., aged 49. Sept. 13, 1871. Has been suffering 
with acute mania for ten days, without any known cause 
except distress in regard to her rent. When I visited 
her she was in bed, with a wild expression, pupils di- 
lated ; her hands were tied to prevent her from destroy- 
ing everything she could get hold of; talk incoherent 
and rambling; refused all food, which had to be admin- 
istered by force; had not slept, except a few hours, for 
ten days. After trying morphise sulphas hypodermi- 
cally, to the extent of one grain, other agents having 



120 ARTIFICIAL ANAESTHESIA. 

been employed previously to my seeing her, hydrate of 
chloral in ten-grain doses was administered every three 
hours. She slept the first night for three hours after 
using thirty grains. She continued its use on the 15th, 
16th, 17th, 18th, and 19th, sleeping longer each night, 
and on the morning of the 20th, when she awoke, she 
was rational, able to eat some soup, and desired to see 
her little girl. She also spoke to her sister, who before 
she would not look at. In corroboration of the above, 
we cite the observations of Dr. A. Holler, Attending 
Physician of the Insane Retreat in Klosterneuburg, and 
Dr. Campbell. Dr. Holler remarks: — 

1st Case. The hydroehloral, during a period of three 
and a half months, failed only twice to produce sleep; 
while, in forty-six days, the exhibition of morphine was 
followed nine times by a negative result. 

2d Case. Catharine B., aged 47 years, suffered from 
religious melancholy; was greatly troubled night and 
day with tinnitus aurium, causing her to pass entire 
nights without sleep. The employment of scruple doses 
of hydroehloral produced several hours of uninterrupted 
sleep. In the course of time it became necessary to 
augment the dose to two scruples. Her pulse sank in 
the mean time to 66, and the quantity of urine (as had 
alread}' been noticed in other cases) was increased. The 
disturbance of hearing diminished very decidedly.* Mr. 
Aldridge examined the eyes, with the ophthalmoscope, 
of patients under the influence of chloral h} r drate, and 
the deductions, if any might fairly be drawn from such 
a small number of instances, would be that the chloral 
hydrate increases the calibre of the arteries, and conse- 
quently the vascularity of the retina, until such times as 
the patient falls asleep, and that the anaemic appearances 
seen at the latter period are those which are said to be 
characteristic of healthy sleep. This fact was first ob- 
served by Dr. Hammond, and published in the New 
York Medical Journal, February, 1870, p. 469. 

* The Journal of Psychological Medicine, April, 1872, pp. 371, 
372, and 404. 



HYDRATE OF CHLORAL. 121 

Dr. John A. Campbell* gives the following results of 
experiments at Garland Asylum, Carlisle: — 

1. That both chloral and tincture of hyoscyamus are 
sure sedatives to maniacal excitement. 

2. That of these two medicines, chloral is the most 
certain sleep-producer. 

3. That chloral acts more quickly than tincture of 
hyoscyamus. 

4. That though bromide of potassium, in gr. xc doses, 
is a sedative to maniacal excitement, and to a certain 
extent hypnotic, yet it is not a sufficiently powerful 
sedative to allay intense excitement, or an hypnotic to 
compel sleep where great insomnia exists. 

5. That a two-drachm dose of tincture of hyosc3 r amus 
is not quite equivalent to thirty grains of chloral. Two 
and a half drachms would probabty be as nearly an 
equivalent as could be given. 

Experiment Seventeenth. — In two cases of delirium 
tremens, from excessive use of mixed drinks, and in 
one after a severe injury, both instances were relieved, 
the first by thirty grains of hydrate of chloral, and in 
the second seventy-five grains were ordered, which gave 
the patient a quiet night, with no delirium, and the cases 
ultimately did well. 

A third case of the above disease was treated with 
equally good results, but its use had to be discontinued, 
owing to so copious a flow of tears obscuring the vision, 
etc. 

Experiment Eighteenth — Case of dysmenorrhea, pain 
relieved by hydrate of chloral. Miss C. G., aged 31, stout, 
and of large frame, has suffered with most distressing and 
painful menstruation for some time ; the pain so severe 
as almost to produce convulsions; menstrual fluid com- 
ing in a gush and then retained. Administered thirty 
grain doses every three hours, with the most happy re- 
sults of relieving the spasm, increasing the flow of the 
fluid and urine, and great relief to the pain. The writer 
has also used it in inflammation of the ovaries with 
equally good results. 

* Journal of Mental Science, January, 1872. The Practitioner, 
April, 1872, pp. 255-6. 
11 



122 ARTIFICIAL ANJESTHES1A. 

Toxical effects on the human system: This drug has 
been emplo3 r ed in hundreds of thousands of cases by 
medical men without producing but very few deaths, 
3'et in the hands of persons not in the profession several 
deaths have followed its indiscriminate use, or rather 
abuse. According to Dr. B. W. Richardson, the maxi- 
mum dose is 90 grains, and witli 140 the sleep would be 
dangerous. Yet deaths have been reported from 60 to 
100, or even 45 grains; but, as stated before, not ordered 
by a medical man, except in one or two instances. In 
recent cases reported by Mr. B. Browning, recovery took 
place after the use of 100 grains, and as much as seven 
pounds has been used, in increasing doses, by one indi- 
vidual without any very injurious results. See also two 
cases of death reported in op. cit., vol. xxvii., August 
17, p. 100, one after four days' use, and one after twelve 
days, quantity not stated. 

Means to be employed in case of accidents in which a 
fatal dose of chloral has been administered : First, ap- 
ply warmth, and furnish warm air. Second, sustain 
the body by an abundance of food, especially warm milk, 
With a little lime-water, and stimulants, say every two 
or three hours, one or two ounces of brandy or whiskey 
to half a pint. Third, keep up artificial respiration by a 
small double acting bellows or other means. It is use- 
ful to add to this, as in Mr. Browning's case, small doses 
of morphine by the hypodermic method. 

Although it is a most useful agent in all convulsive 
diseases as a pain reliever, it will not always, nor could 
it, take the place of morphine. It has been found very 
valuable in causing sleep, and even curing cases of teta- 
nus and trismus. There have been, up to June, 1871, 
thirty-six cases of tetanus treated by this agent and the 
galvanic current, in which there has been twenty-one 
recoveries and fifteen deaths. In one case the dose was 
60 grains eveiy half hour, and the patient took seven 
doses and recovered. It has been found useful in the 
paralysis of the insane, and yet in some instances it pro- 
duces a partial paralysis of the organs of deglutition; 
also restlessness, and even coma. 

It is antagonistic to the poisonous effects of calabar 



HYDRATE OF CHLORAL. 123 

bean and strychnia, and yet is given in combination 
with them.* 

Dr. II. Griffin reports a successful case in 1872 b} 7 means 
of chloral, morphine, and galvanism. M. Gamier refers 
to several cases in which chloral was used in the treat- 
ment of tetanus occurring in very young persons; two 
cases were cured. The writer finds another case of death 
from chloral, reported by Dr. W. H. Lathrop, occurring 
in the practice of another physician, in which 100 grains 
were given ; after the last dose of 20 grains the two phy- 
sicians left the house, when they were called back to find 
the patient dead, who prior to their leaving, it is stated, 
complained of a slight paralysis in the right lower ex- 
tremity, which no doubt extended to the heart. A post- 
mortem examination revealed nothing. This is like one 
or two fatal cases related by Dr. N. R. Smith, of Balti- 
more, in which, when given in large doses (60 gr.), and 
where the system may have become charged with it, it 
overwhelms the powers of life, as is the case in some 
instances by the hypodermic use of morphine, aconite, 
strychnia, etc. According to Dr. Richardson's observa- 
tions, it should be given in repeated doses, at the rate 
of ten grains every two hours, or seven grains every 
hour; but the pulse, heart, and skin should be carefully 
watched. Dr. Nathan R. Smith describes its effects 
upon the fingers, attended by desquamation of the cuti- 
cle and superficial ulceration; but so far as our observa- 
tion goes, and that of many physicians, no such results 
followed its use, and his cases are exceptions which it 
will be well to remember as results which may be en- 
countered. 

Hydrate of chloral has been found to act beneficially 
in a number of cases of puerperal convulsions ; and Dr. 
Liebreich is disposed to explain this by accepting F re- 
rich's theory, that the convulsive attacks are connected 
with the transformations of urea into urate of ammonia, 
and by supposing that besides the production of chloro- 
form there is a formation of hydrochloric acid, which 
neutralizes the ammonia. Among other diseases in 

* See table by Dr. Joseph R. Beck, p. 299, in the St. Louis 
Medical and Surgical Journal, June, 1872. 



124 ARTIFICIAL ANESTHESIA. 

which there has been a general agreement of opinion as 
to the beneficial effects of hydrate of chloral, Dr. Lie- 
breich mentions senile nervous asthma, not noticed be- 
fore in this paper, dental convulsions in children, sea- 
sickness, etc. The following are our conclusions, as 
drawn from our experiments, observations, and the most 
recent literature upon this interesting subject: — 

1. The action of chloral hydrate differs from that of 
chloroform. 

2. That the action is the result of the conjoined use of 
chloroform and formic acids upon the blood. 

3. A part of the chloroform formed by the action of 
the alkali of the blood is eliminated by the pulmonary 
mucous membrane ; apart of the formic acid is elimi- 
nated by the urine as formiate of soda, as shown by ex- 
periments of "Byasson" (French Academy, June 12, 
1871). 

4. There are three degrees of the operation of chloral 
on animals and man, as shown b} T our own experiments. 

The first degree is feebly soporific, and slightly ner- 
vous sedative action. 

The second degree is an intense soporific action, with 
diminution of sensibility; at this period there is a deep 
sleep of variable duration, without apparent trouble of 
the principal functions of life. 

The third degree, complete anaesthesia, with total loss 
of general sensibility and muscular power, cataleptic 
state. Deatli almost always follows this degree of action, 
as was seen in our experiments on animals. 

5. Under the microscope the blood was seen moving, 
with some bright red, or dark red particles. According 
to " Ralph," starchy bodies are also met with in both 
urine and blood. 

6. Death takes place last at the heart, which is kept 
in action long after all signs of death in the animal were 
present, as shown by removing the sternum, etc. 

7. Sleep, with diminished heat of the surface one or 
two degrees below the natural standard. 

8. Small doses do not produce anaesthetic results, 
these requiring from forty to fifty 7 grains. In typhoid 
and typhus fevers one must commence and continue in 
small doses ; five grains is the average quantity required. 

9. It increases the flow of the menstrual fluid. 



HYDRATE OP CHLORAL. 125 

10. Seventy grains of the hydrate of chloral is equal 
to i grain of morphine employed hypodermically, and is 
not apt to cause so much disturbance of the stomach. 

11. Gout and rheumatism must be treated with an ex- 
cess of alkali, potassa, or soda, to obtain the best results 
from its use. 

12. Males require a larger dose than females. 

13. It is very valuable in diseases of little children, but 
care must be exercised to commence with small doses, 
gr. j for each month, and it should be mixed with no- 
thing but water, as it is so apt to change and become 
worthless in contact with organic matter. 

14. Hydrate of chloral will be found useful in phthisis, 
and even some forms of acute affections of the lungs, 
but not when the heart is involved. 

15. It is a most valuable agent in nervous affections. 

16. In affections of the e} r e it requires care to use it, 
as it is apt to cause swelling and redness and excessive 
flow of watery secretions, witli obscuration of vision. 

17. In sunstroke or heat toxaemia it is a most valua- 
ble aid to produce sleep in that restless state after reac- 
tion produced by frictions of ice and ice- water to the 
head and body. 

18. In tetanus it has been found a most pleasant 
agent in arresting the fearful paroxysms and giving the 
patient rest, and assisting materially to the cure, caus- 
ing a relaxation to the affected muscles, and by counter- 
acting the effects of the spasm. 

19. In cases of impending death the means are to 
support the system by heat, food, and artificial respira- 
tion, with stimulation and small doses of strychnia. 

20. It has been found a most valuable agent in acute 
mania and in the paral3*sis of the insane, delirium tre- 
mens, dysmenorrhcea, and tinnitus aurium. 

21. Comparative^', trials prove it more valuable in 
maniacal cases, in producing sleep, than tincture of hy- 
oscyamus or bromide of potassium. 

22. Chloral is very useful in the convulsions of chil- 
dren (when there is no severe affection of the bronchi, 
heart, or lungs), but care must be employed not to ad- 
minister it if the infant or child is very anaemic or in an 
exhausted condition, as in the case of a wasting disease. 

11* 



126 ARTIFICIAL ANAESTHESIA. 

23. The necropsy in case of death from hydrate of 
chloral sliows anaemia of the brain, acute oedema of the 
lungs, hyperemia of the abdominal organs, and dark 
fluid blood in the vessels. 

On Chloral as an Anaesthetic. 

The London Medical Times and Gazette, Oct. 21, 1876, 
states that at the late Medical Congress at Brussels, 
Dr. Boucliut " observed that he took that opportunity of 
again directing attention to the fact that children can 
be placed in a state of absolute anaesthesia by means of 
chloral given by the mouth in doses of three or four 
grammes, and without producing pyrosis, gastritis, vom- 
iting, or diarrhoea. It commences a quarter of an hour 
after the injection of the chloral, and is complete at 
the end of an hour. If, at this period, an abscess be 
opened, caustic applied, or a tooth extracted, the sleep- 
ing child may heave a sigh or move a limb, and again 
become immovable, waking up four hours afterwards 
quite unconscious of what has passed. This is a new 
proof of the difference which exists in the action of cer- 
tain medicinal substances in adults and in children. 

Mr. Couty, of Paris, finds that when animals are killed 
by chloroform, ether, or chloral, the muscles and motor 
nerves retain their irritability much longer than when 
death is produced by bleeding, compression of the heart, 
or asphyxia. This is especially marked in the case of 
chloral. We have repeated these experiments with 
chloral on frogs, and showed the results before the 
Philadelphia County Medical Society, and published 
the results in the Phila. Med. and Surg. Reporter. Mr. 
Couty considers the cause of this phenomenon to consist, 
not on any action of the anaesthetics on the spinal cord, 
but in a direct modification of the nerves and muscles 
by them through the blood, similar to that which occurs 
in poisoning by carbonic oxide. 

Prof. Ore, of Bordeaux, has introduced the intra- 
venous injection of choral as a means of producing gen- 
eral anaesthesia; he employs the following formula: — 

R. — Hydrate of chloral, 10 grammes. 
Distilled water, 30 grammes. 



CHLORAL POISONING. 127 

A graduated hypodermic syringe is emplo3 r ed, gold 
trocar and canula. A band is placed on the arm above 
the point selected, and when the vein has become promi- 
nent it is pierced through the skin and 50 centigrammes 
are to be injected after removing the band. If anaesthe- 
sia is not produced, one gramme is added at a time un- 
til the patient complains of a strong inclination to sleep, 
when the canula is withdrawn. From six to ten grammes 
are stated to be required for an adult. The author adds 
this caution: It is an indispensable precaution to have 
an electrical or galvanic apparatus at hand, in order to 
arouse the patient from his insensibility by passing a 
current along the course of the pneumogastric nerve. 
Advantages: Absence of stage of excitement, and of nau- 
sea, and vomiting. Accurate graduations of dose, abso- 
lute characters of the anaesthesia, muscular relaxation 
and prolonged blunting of the patient's sensibility, which 
protects him from shock. Risks : Thrombosis and em- 
bolism, irregularity of the heart's action, presence of 
blood and albumen in the urine, and above all, risk of 
fatal syncope and death. 

Chloral Poisoning.* 

Dr. J. Milner Fothergill, of London, recommends (in 
Medical Times, Phila.) the great utility of strychnine 
as a true expectorant in bronchitis when the stage of 
free secretion is reached, and the air-tubes are full of 
mucus and the patient is in danger of choking. A com- 
bination of carbonate of ammonia, tincture of mix vom- 
ica, and tincture of squill, is a most excellent mixture 
for patients suffering from dyspnoea, and generally pro- 
cures them "more breath," as they phrase it. One of 
the most important matters connected with such use of 
strychnine is its relation to sleep. In a case seen re- 
cently by him of complex lung and heart mischief, to 
which was added chloral poisoning, the good effects of 
strychnia were well marked. The patient was almost 
at once relieved from the attack of dyspnoea, in the mid- 
dle of the night, to which he had long been subject. By 

* The Council of the British Pharmaceutical Society passed a 
resolution that chloral hydrate and its preparations ought to be 
regarded as poisons within the meaning of the Pharmacy Act. 



128 ARTIFICIAL ANAESTHESIA. 

the use of strychnia during the day, a narcotic pill at 
bed-time is often deprived of its tendency to produce 
nocturnal dyspnoea. We might add that strychnia, in 
combination with ammonia and senega, might be found 
very useful in the after-treatment of congestion of the 
lungs, from the excessive use of sulphuric ether and al- 
cohol; it is surely worthy of trial. 

Hydrate of chloral, when given in large doses, some- 
times causes dangerous symptoms, followed by sudden 
death. Several instances are recorded of medical men who 
have taken it incautiously and have died from its effects ; 
two cases are reported in the Med. Times and Gaz., 
1871, vol. i. p. 367, and of late they have become 
numerous. The deaths have been sudden, and no re- 
markable symptoms have preceded dissolution, as ob- 
served by Dr. Taylor.* The person has passed at 
once from sleep into death. One case proved suddenly 
fatal by causing paralysis of the heart (Lancet, 1871, 
vol. i. p. 440). M In the fatal cases which have occurred, 
the principal appearances noted were congested state of 
the brain and its membranes." Drs. Taylor and Tuke 
have given it as their opinion, based upon one case, that 
the long-continued use of chloral might have produced 
a diseased condition of the brain, which, by the sudden 
withdrawal of the narcotic, might have rendered the 
part} r accused of murder (a man in a fit of passion, for 
some trivial cause, throws a petroleum lamp at his wife, 
which ignites her dress, and death is the result by 
burning). I have directed the employment of chloral 
hydrate in solution in medicinal doses for one year as a 
sedative and narcotic, and the only disagreeable result 
complained of by the patient was that it caused a hot feel- 
ing, with free perspiration, as if she was in a hot batli ; it 
was withdrawn at the end of that time without producing 
the least disturbance of the brain, inflammation of the skin, 
or loss of memory or intelligence. We have had no fatal 
cases of this kind, therefore, I believe that other causes 
besides the hydrate of chloral may have produced some 
of the recorded results. 

In the treatment of large doses of the hydrate of 

* On Poisons, op. cit., p. 616. 



NITROUS OXTDE GAS. 129 

chloral, the stomach pump should be used and the stom- 
ach well washed out with strong decoction of green tea, 
and the same treatment as from poisoning by opium. 



CHAPTER VI. 



Nitrous oxide gas as an anaesthetic. Practical observations and experi- 
ments of Dr. J. D. Thomas. The Thomas inhaler, description and 
mode of use. Mode of manufacturing nitrous oxide for inhalation. 
Impurities and mode of purification. Mode of administration Use of 
prop in extracting teeth, while under its influence. Risks, and treat- 
ment of accidents. Coxeter's form of cylinder for liquid nitrous 
oxide. 

Nitrous Oxide Gas. 

In entering upon the subject of nitrous oxide it is not 
my purpose to go into its discovery, early history, etc., 
as a short statement is made in another part of this 
work, and numerous references are given for those that 
are interested. This anaesthetic can be employed in a 
few operations in surgery; these are, extraction and sur- 
gical operations on the teeth and gums. With it the 
ophthalmic surgeon can operate for ordinary strabismus, 
or removal of small tumors, or even the diseased eye- 
ball. It is very valuable in examining the urethra for 
stricture, and even cutting of an impervious stricture 
has been performed with success. A recent luxation, 
or stiff joint, or the tenotomy of tendons for the relief 
of club foot, etc., have all been performed while under its 
influence. My chief object will be to treat of this anaes- 
thetic in its practical relation in connection with den- 
tist ry. 

Thomaa 1 s Inhaler. — The late Dr. Thomas had con- 
structed a valuable inhaler, which he employed in his 
numerous operations, and his brother, Dr. J. D. Thomas, 
has continued to use it, with so much satisfaction that at 
my desire he has described it as follows (see Fig. 17), and 



130 ARTIFICIAL ANESTHESIA. 

I have had a cut made, and approved by him. The inhaler 
is turned from a piece of vulcanized rubber, eight inches 
long by three inches square, leaving the mouth-piece one 
inch and a half across. The diameter of the opening is 
a little more than one-half an inch, with stopcock in the 
centre, in which is the inhaling valve, which is con- 

Fis:. 17. 




MOUTH 



structed of a simple piece of rubber dam secured by a 
pin to a stopple, in which are three oblong apertures, as 
is the inhaling valve at the extremity of the inhaler. 
The aperture being of suflicient size, is made not to ob- 
struct the free passage of the nitrous oxide gas, the 
valves are three-quarters of an inch in diameter, and the 
stopple is of vulcanized rubber. His method of using it 
will be described in his lecture. 

Manufacture of Nitrous Oxide Gas. 

Nitrous oxide gas (XO — N.,0) is prepared from nitrate 
of ammonia. This is a crystalline salt, but for conveni- 
ence of introduction into the retort, should be in a gra- 
nulated form, which can be obtained of the manufactur- 
ing chemist. 

The second important matter is to be furnished with a 
convenient gasometer, an illustration of which is seen at 
Fig. 18, and these can be obtained from the various dental 
depots.* Having obtained one of these convenient gas- 
ometers, care is required in the selection of the bottles for 

* Of Dr. S. S. White, in the chief cities of the United States. 



MANUFACTURE OF NITROUS OXIDE GAS. 131 

Fig. 18. 




132 



ARTIFICIAL ANAESTHESIA. 




Fig. 19. washing and purifying the gas. Fig. 

19 represents a very good form, 
which is furnished with perforated 
rubber cork and glass tubes bent at 
right angles, the long tube is pierced 
with small holes at the bottom to 
compel the breaking up of gas, and so 
insure its more thorough washing. 
In purifying the gas some employ a 
solution of sulphate of iron in one bot- 
tle and pure water in the other two. To 
remove chlorine gas, which is some- 
times present, and can lie noticed by 
its green color and irritating vapor 
upon the respiration, a small stick of 
caustic potash is added to one of the 
bottles containing the water. 

When no chemical agents are em- 
ployed in the purification of the gas it should be well 
washed through fresh water, and allowed to stand for 
some few hours over the water in the gasometer, to 
remove any impurities that may have passed over. 

Fig. 18 represents the gasometer in position. The holder 
is first filled with water to within one and a half or two 
inches of the top; while this is being done take off the 
weights and open all the spigots, to allow the air to 
pass out and the receiver to remain in position. When 
the holder is filled, close the spigot and arrange the 
weights; it is then ready to receive the gas. The wash- 
bottles are placed as represented in the cut, Nos. 1, 2, 
and 3, which are connected one with the other, and to 
the retort and gasometer, by means of rubber tubing. 
The first bottle, No. 1, is placed next to the retort, and 
is simply used to catch the drip resulting from condensed 
vapor. 

The long pipe of bottle No. 1 must not dip under the 
water, for the tubing thereby becomes choked with dense 
vapor and the free passage of gas is interrupted. 

Into wash-bottle No. 2 place about four ounces of sul- 
phate of iron, and add sufficient water to cover the end 
of the dip-pipe, about one and a half to two inches. 
Into wash-bottle No. 3, Fig. !'.>, it is unnecessary to 



MANUFACTURE OF NITROUS OXIDE GAS. 133 

place arching but fresh water; yet some, fearing the 
chlorine, add a stick of caustic potash. 

Sufficient water should be employed to cause the pipe 
which dips into the water to sink the same depth as it 
does in No. 2. 

When the bottles are prepared, connect them by the 
piece of rubber tubing B, and to the spigot of the gaso- 
meter. If they are arranged properly, a current of air, 
blown into the tube intended to connect with the retort, 
will cause the water to bubble in the wash-bottles, Nos. 
2 and 3, and if the spigot A is open, the receiver will 
commence to ascend. 

Having the bottles in readiness and properly con- 
nected, place the quantity of nitrate of ammonia, which 
will be required, into the retort (one pound of the granu- 
lated salt will produce about thirty gallons of the gas). 
D is a stove-like arrangement heated by gas-burners, with, 
a sand-bath for holding and heating the retort. Con- 
nect the retort with the long pipe of the first bottle by 
the rubber tubing, and then open the spigot of the gas- 
ometer. 

The heat must be applied gradually, first to melt the 
ammonia, about 226° F., and then to cause it to boil, 
and give off gas at 460° F., and so regulate this heat as 
to keep it boiling at 460° F. to 480° F., until it is nearly 
all decomposed. When the gas has ceased to come over, 
take a cloth and disconnect the retort from the tubing 
and close the spigot of the gasometer. 

The inhaling tube is attached to the spigot at the top 
of the holder. 

There is a register which shows the number of gallons 
of the gas in the receiver. 

The water and solutions contained in the wash-bottles 
should be changed after each operation, and the water in 
the holder once in a month. When nitrous oxide gas is 
thus obtained, it is colorless, almost inodorous, of a 
sweetish taste. The chemical decomposition is as fol- 
lows: nitrate of ammonia resolves itself into nitrous 
oxide gas and water; thus, N0 3 NH 4 =OH + 2NO. The 
heat necessary to cause active evolution of gas is stated 
to be 460° F., and this heat should be kept up, else a por- 
tion of the salt will sublime. The heat should never be 
12 



134 ARTIFICIAL ANAESTHESIA. 

allowed to rise above 482° F., as the nitric oxide is apt 
to be given off in the form of an orange-colored vapor. 
To determine the proper temperature a thermometer is 
prepared which can be passed into the cork and into the 
retort, so that no risk need be incurred by the introduc- 
tion of poisonous materials into the gas. 

By condensation nitrous oxide gas will become a 
liquid,* and as such is sold in Coxeter's form of cylinders, 
and is to be had of Mr. Samuel S. White, of this city. 

Messrs. Coxeter's test of the purity of their nitrous 
oxide is the appearance of the gas, and its freedom from 
red fumes as it comes from the retort, and the smell. 

"The complete apparatus consists of an iron cylinder 
containing at least 100 gallons (usually more) of nitrous 
oxide, liquefied, to which is attached by means of a 
nickel-plated union the necessary tubing, gas-bag, and 
inhaler; nLkel-plated wrench and key; the w r hole in- 
closed in a stout merocco case. 

u The inhaling tubing is made of the best material 
known for the purpose. 

" The gas-bags hitherto sold have been a source of 
annoyance and complaint on account of their flimsy cha- 
racter and their liability to burst. Those now offered 
cannot fail to give satisfaction. They are made of stout 
muslin, thoroughly coated on both sides with pure l steam 
vulcanized' para rubber. 

u Their parts are all cemented together before putting 
them in the heater, insuring a strong vulcanized seam. 

M The advantage of this method of construction is seen 
at once. If accidentally cut or burnt, or mutilated on 
the outer surface, they are still good and serviceable, as 
the inner coating remains intact, and will prevent all 
leaking." 

4t | After this brief description of the process of its man- 
ufacture, as it has been set forth, I would remark that 
some use the fused and others the granulated nitrate of 
ammonia. I consider the granulated preferable, only 
from the facility with which you can fill the retort. 
After the gas is made, it should stand over water from 

* "Liquefied Nitrous Oxide," Dental Cosmos, vol. xx., No. 3. 
f From Dr. J. D. Thomas. 



MANUFACTURE OF NITROUS OXIDE GAS. 135 

seven to ten hours before using, but this will do little 
towards insuring absolute purity of the gas; neither will 
washing it through solutions of iron and potash purify it 
perfectly. Should there be chlorine present (which is 
the poisonous element) in the ammonia, I have found 
that no amount of washing through solutions will oblit- 
erate it. The ammonia should always be tested before 
using, which is done by dissolving about a teaspoonful 
in half a tumbler of distilled water, and appljing a few 
crystals of the nitrate of silver. If the ammonia be 
pure, the solution will remain perfectly clear; but, should 
chlorine be present, it will show a clouded appearance, 
and the ammonia must be discarded altogether. 

Next to pure gas, a perfect inhaler is the most essen- 
tial object to the successful administration of nitrous 
oxide; it must be one with a tube large enough to admit 
the gas so freely that the most nervous as well as pa- 
tients with weak lungs can inhale through it without 
exertion; and it must be perfectly air-tight. The ma- 
jority of inhalers are so constructed that it is only with 
using great effort that patients can supply the lungs to 
their natural capacity, causing them to struggle for air, 
or go to sleep with such feelings of suffocation and de- 
pression that they will drift into dreams of the most 
frightful character, and become almost unmanageable in 
their excitement. 

It is necessary that the valves should be perfectly air- 
tight, so as to administer the gas free from any atmo- 
spheric air, one breath of which is sufficient to dilute 
two or three of the gas, and should there be a continual 
supply through the valves, it will require three times the 
quantity' of gas, and the anaesthesia so produced will 
be of such a nature as not to render the patient utterly 
oblivious to the effects of the operation. 

Inhalers which cover the face or any part of it are ob- 
jectionable. In cases of gentlemen with beard, it is im- 
possible to give the gas without the admission of some 
air. In instances, such as harelip, or where, from swell- 
ing or other cause, the muscles of the jaws become 
so contracted as to render it impossible to pass the 
mouthpiece between the teeth, I would recommend Dr. 
Barker's rubber hood, which is soft and pliable, and 



136 ARTIFICIAL ANAESTHESIA 

answers admirably in such cases, though not desirable 
for universal use. The color of the blood, as shown 
through the mucous membrane of the lips, is one of the 
principal guides to the condition of the patient during 
the inhalation of the gas; and if they are covered from 
view by the hood or otherwise, we have lost that means 
of rendering success to the operation. 

Unlike chloroform and ether, the muscles of the pa- 
tient become rigidly contracted while under the influence 
of nitrous oxide in a large number of cases, which ren- 
der the use of props indispensable. These are made of 
hard wood of various sizes, and have strings attached 
to assure the patient against the possibility of swallow- 
ing them, and are placed in the mouth on the side oppo- 
site from where the tooth is to be extracted. By their 
use one has a fair opportunity to perform the operation 
to his entire satisfaction; but without them there is 
danger of the patient bruising and possibly breaking the 
front teeth by biting so hard upon the mouthpiece, with 
the probability of recovering from the effects of the gas 
before the mouth can be gotten open sufficiently wide 
to admit of the extraction of a tooth. (Here a number 
of inhalers were exhibited, and their qualities explained. 
After which, the mode of administering was illustrated, 
together with position, the importance of an assistant, 
and the symptoms during the inhalation. In extracting, 
the kinds of forceps required, and how to use them, and 
the importance of having in the mind just what was to 
be done, so as to instantly commence the operation.) 

Nitrous oxide must always be fresh to insure success, 
though some have recommended it after it has stood 
over water one or two weeks, and even a month, but it 
is impracticable. 

Two years this fall my brother, who is now deceased, 
was attending medical lectures at the Jefferson College. 
Dr. Hand, the late Professor of Chemistry at that insti- 
tution, advocated old gas; and, to practically demon- 
strate the difference, we allowed some gas to stand for 
two weeks, then invited him to test between that and 
the new. He invited his assistants, Drs. Green and 
Smith, and tested by inhaling with deep inspirations to 



MANUFACTURE OF NITROUS OXIDE GAS. 137 

the full capacity of the lungs, first of the new, then the 
old, and it required five times the quantit}' of the old to 
produce the effect with the new, which proved quite con- 
vincing. Besides requiring an excessive quantity, the 
anaesthesia produced by old gas is not so complete but 
what the patient will mostly receive some undefined im- 
pression of the operation, and they will often complain 
of giddiness and a fulness in the head, and feeling gen- 
erally miserable for the balance of the day. With fresh 
gas, sickness will never occur, except with patients of 
very delicate organizations, who are easily disturbed by 
nervous excitement, and those who are affected by the 
sight of blood, or the contemplation of a wound of any 
kind. 

In its pure state the gas may be given to almost any 
one, I believe, with impunity,'if judiciously administered, 
for I have given it to a large number of patients afflicted 
with heart disease and consumption, also to cases sub- 
ject to epileptic fits, St. Vitus' dance, persons of apo- 
plectic tendency, and women advanced in pregnancy, 
and have never yet met with any but the most satisfac- 
tory results. 

Among the difficulties } t ou may meet having the ap- 
pearance of danger in administering nitrous oxide, the 
most common will be the constriction of the glottis or 
8 wallowing the tongue. The use of the prop cannot be 
overestimated in such cases. The patient becomes very 
dark in the face; there is a violent exertion of the dia- 
phragm, and presents every indication of approaching 
asphyxia, which, having the mouth well propped open, 
is very readily relieved by catching hold of the tongue 
with a dry napkin and pulling it out of the mouth, and at 
the same time raising the body forward ; as soon as the 
patient has taken two or three inspirations the tension is 
relaxed, and he will recover in a minute's time. I recall 
to my mind a case of this sort in Exeter, England, where 
the patient died some time ago.* 

The most formidable appearance of danger is when 
your patient is attacked with syncope while under the 
influence of the gas. You want first to be sure the air- 

* Described in " The Dental Cosmos," May, 1873. 
12* 



138 ARTIFICIAL ANAESTHESIA. 

passages are open by getting the tongue forward. Then, 
the patient being in a sitting posture, bring the head and 
body forward with considerable violence, which will in- 
variably prove sufficient. You may, however, meet 
cases which will require more effective remedies. The 
object is first to get the head on a level or below the 
heart, so the blood may flow freely to the brain, which 
is done by laying the patient on the floor, then throw- 
ing cold water by the tumblerful violently in the face. 
In my experience I have found the most effectual 
remedy is to place the finger far down the throat, 
which will produce involuntary retching, and is the 
most efficient action to bring about restoration, after 
which you treat the same as any ordinary case of faint- 
ing, giving a little brand)-, and allowing him to lie on 
the lounge until he has become strong enough to walk 
in the fresh air, when he will soon recover completely." 
In the hands of so skilful and careful an operator as 
Pr. Thomas, no great risk attends the employment of 
this anaesthetic; but those who are less skilful and are 
inexperienced should reject cases of great physical ex- 
haustion, or patients with a feeble or fatty heart. The 
distension of the right cavities which accompanies the 
disappearance of the radial pulse, and the general lividity 
of the features, may be attended with some degree of 
risk, and the danger must be increased when, the muscles 
of the trunk and limbs being convulsed, the pressure of 
the contracting muscles upon the veins drives the blood 
forcibly towards the right cavities of the heart, and so 
adds to their distension. 



ACTION OF NITROUS OXIDE GAS. 139 



CHAPTER VII. 

Physiological action of nitrous oxide gas. Resemblance between the 
effects produced by nitrous oxide and asphyxia. Summary of the 
facts bearing on this subject. Not merely a passive agent. Dr. 
Evans' (of Paris) experiments with nitrous oxide and other gases, 
and his conclusions Dr. J. H. McQuillen's experiments in 1868, and his 
repeating them in conjunction with the writer. Personal experiments 
of Dr. Jeannel in 1S69 ; he dwells upon the non-fatal character of 
nitrous oxide, and the rapidity with which its effects pass away. 
Also the corroborative experiments of M. Limouzin. Original ex- 
periments of Dr. Robert Amory in 1870, with his conclusions, 
and opinions of Dr. Johnston. Mode of action of anaesthetics. Ex- 
periments of Professors Heinrich Ranke and D. C. Binz on morphia, 
chloral, ether, chloroform, amylene, bromoform, and bromohydrate. 
Physiological action of nitrous oxide gas, by the editor of " Binz'a 
Therapeutics." List of authorities on the nature and action of chloro- 
form, ether, and nitrous oxide. Deaths from the inhalation of nitrous 
oxide. Post-mortem changes, etc. 

Physiological Action of Nitrous Oxide Gas. 

The marked resemblance between the effects pro- 
duced by nitrous oxide and those resulting from as- 
phyxia was observed by the earlier experimenters with 
ether; and a few eminent physiologists at once ex- 
pressed this opinion ; but at the present day it is not 
very generally entertained.* 

The following is a summary of the various facts bear- 
ing on the subject, i. e., in regard to the physiological 
action of nitrous oxide : — 

" It would seem that this accumulated evidence is suf- 
ficient to show that the anaesthesia produced by the in- 
halation of nitrous oxide is simply asphyxia ; yet it is 

* A Treatise on Therapeutics and Toxicology, p. 241, 2d ed. 
Dental Cosmos, from Jan. 1869, to April, 1870; continued in five 
numbers. J. B. Lippincott, Phila. 



140 ARTIFICIAL ANAESTHESIA. 

stated that it produces in man, even when mixed with 
air, a feeling of exhilaration, which would indicate that 
it is not merely a passive agent." " Dr. Evans,* of Paris, 
states that he can call to mind no word in modern medi- 
cal literature which is used with less definiteness of mean- 
ing, and which is more frequently misused, than this 
word asphyxia. Understanding, however, by the word 
asphyxia, the condition which arises from an insufficient 
oxygenation of the blood, or from the accumulation in 
the blood of carbonic acid, he is by no means inclined 
to regard such conditions as identical with that pro- 
duced by the inhalation of nitrous oxide. If there is a 
close resemblance between these, he states, there are 
also marked differences. 

Nitrogen,- when inhaled, is supposed to act upon the 
animal economy solely by the exclusion of oxygen. 
Nitrogen, "when taken into the lungs, gives rise to no 
feeling of exhilaration, but to malaise and a sense of 
impending suffocation, and only occasions symptoms of 
narcosis and insensibility after an interval of time con- 
siderably greater than that usually found necessary 
when nitrous oxide is used. 

In animals, after death following the inhalation of 
nitrogen, Dr. Evans has generally found less venous 
congestion, particularly of the portal system, than is to 
be observed after death from nitrous oxide. The blood 
is also lighter in color, and the liver nearly normal in 
appearance. 

There is, however, one condition strikingly similar to 
that observable after death from nitrous oxide, i. e., the 
condition of the lungs. These organs are found neither 
voluminous nor collapsed, of a light pink or rose color, 
and generally with one or more small circular, well- 
defined ecclymotic spots, usually on their posterior sur- 
face. These spots, the ecchymoses sous yle.urales of 
French writers, are considered by Briand and Chande 
as peculiar to death by suffocation, and as distinguish- 
ing that kind of asphyxia from the asphyxia of drown- 
ing, hanging, and strangulation. The phenomena 
occasioned by the presence of carbonic acid were then 

* Physiological Action of Nitrous Oxide Gas, by Thomas W. 
Evans, M.D., D.D.S., Paris, France. 



ACTION OP NITROUS OXIDE GAS. 141 

carefully studied by experiments by Dr. Evans. This 
ga& when pure is irrespirable ; the mixture which he 
employed was 30 per cent, of carbonic and TO of com- 
mon air. This mixture when inhaled produces the 
peculiar effects of carbonic acid, loss of power of motion, 
loss of conscious sensation, and finally, death. The in- 
sensibility is not preceded by a period of excitement, 
such as is witnessed during the inhalation of ether, and 
more especially of nitrous oxide. Again, the after- 
effects following a prolonged inhalation of carbonic acid 
are observed — the sense of weariness, headache, loss of 
appetite, nausea, etc.; none of these signs of nervous 
disturbance are commonly seen after inhalation of nitrous 
oxide. This is an important difference, not only practi- 
cally, but physiologically. 

After death from nitrogen or nitrous oxide, the lungs 
are moderately crepitant, and the blood which escapes 
from an incision is more or less full of gas bubbles. In 
case of death produced by nitrous oxide, the bubbles 
will be found in the bronchial ramifications mixed with 
mucus, and in one or two instances, Dr. Evans found 
the trachea filled with rusty, frothy fluid, so common 
after drowning as to have been referred to by Dr. Rie- 
dell as almost pathognomonic of that cause of death. 
The local effects of nitrous oxide were found to be less 
marked than those produced by carbonic acid. They 
both act upon the blood-corpuscles so as to darken 
them. The lividity upon the lips, and the darkening of 
the mucous surfaces seen every day in the operating 
room after administrations of nitrous oxide, are the re- 
sult of this action. The inhalation of nitrous oxide is 
followed by an increased exhalation of carbonic acid ; 
so is the inhalation of ether, chloroform, etc. Soon, 
however, according to M. Buisson, if the inhalation be 
continued, the exhalation of carbonic acid falls below 
the normal proportion to be found in expired air. 

While it is perfectly evident that nitrous oxide has 
a strong affinity for the blood-corpuscles, it may usurp 
the place of oxygen in them, and prevent for a time 
that combination of ox} T gen with the hsematin upon 
which the red color of the corpuscles is presumed to 
depend. Chemistry has not yet shown that it is decom- 



142 ARTIFICIAL ANAESTHESIA. 

posed in the blood, or exerts any of the chemical prop- 
erties of oxvgen on the constituent elements of the 
blood." 

Th(4, conditions which obtain after the inhalation of 
nitrous oxide, ether, chloroform, and other anaesthetics, 
are, specific toxical properties, which first stimulate, 
then narcotize, then destroy nervous action : by (a) 
an interference more or less marked with the oxy- 
genation of the blood, and the consequent imperfect 
accomplishment of certain chemico- vital processes; by 
(6) a retention in the blood of a portion of the usual 
pulmonary exhalations : the two latter and secondary 
conditions always finally co-operating with the specific 
action of the anaesthetic in the production of narcosis, 
the arrest of innervation, and in the suspension of every 
functional movement; in a word, in the death of the 
organism. Latterly it has been disproved both by expe- 
riment and observation, i. e., the theory which for a time 
prevailed in the United States, "that nitrous oxide acts 
upon the blood as an oxygenating agent." No ex- 
perimental proof has yet been furnished that nitrous 
oxide is decomposed in the blood, or forms chemical 
combinations with it. It enters into the blood as nitrous 
oxide, and as such is eliminated. It will naturally be 
inferred from this statement that the presence of nitrous 
oxide in the blood is not indicated by the appearance 
(except change of color), as before stated. This was 
very conclusively proven by Dr. J. 11. McQnillen, Pro- 
fessor of Phj'siology in Philadelphia Dental College, 
which proofs are here given with the illustrations. 

By the kindness of Dr. Thomas, of this city, of the 
Colton Dental Association, was placed his whole appa- 
ratus, with a large supply of recently made pure nitrous 
oxide gas, at the disposal of Dr. McQnillen and myself, 
and we repeated the experiments (see p. 148) in confir- 
mation of the facts: that the gas had no positive 
poisonous qualities; second, that the blood-corpuscles 
were changed neither in form nor color under the micro- 
scope, and nitrous oxide is only known b}- the change of 
color, and even this varies much in individuals. A full 
report will be found at the end of his original communi- 
cation. 

Dr. McQnillen has placed this communication at my 






ANESTHETICS ON THE BLOOD-CORPUSCLES. J 43 

disposal, with the cuts to illustrate it, and made puch 
modifications of it as time and his mature judgment 
would seem to have dictated. 

Action of Anaesthetics on the Blood-Corpuscles.* 

In the October number of the Dental Cosmos, 1868, a 
report was presented of a series of experiments per- 
formed by me, on a number of animals, with the view of 
ascertaining whether the assertion made by Dr. B. Ward 
Richardson, that nitrous oxide, even under the most 
delicate manipulation, would prove destructive to life, 
could be possible. These experiments, which clearly 
demonstrated the assertion to be unfounded, were not, 
performed in private, but in the presence of a number of 
gentlemen whose experience in the use of anaesthetics 
and whose scientific knowledge made them competent 
judges. First performed before the members of the 
Odontographic Society of Pennsylvania, they were re- 
peated, after an interval of three weeks, on the same 
animals, in the presence of the members of the Biologi- 
cal and Microscopical Section of the Academ}' of Natu- 
ral Sciences. 

A month subsequent to the last-named occasion, one 
of these animals, a rabbit, in the presence of a number of 
gentlemen, was placed under the influence of nitrous 
oxide, and kept in a profound state of narcosis for one 
hour and Jive minutes, by alternating atmospheric air 
and nitrous oxide, removing the inhaler ever and anon 
for that purpose. Without question the animal could 
have been kept in the same condition double or treble 
the time without injury to it, for in a few minutes after 
removing the anaesthetic entirely, the animal was re- 
stored to consciousness, and leaped from the table to 
the floor, and for a number of weeks after this ran about 
my premises in a healthy and lively condition. 

On examination no perceptible difference was observa- 
ble in the blood-corpuscles under the microscope, even 

* Republished in the Boston Medical and Surgical Journal ; 
Monthly Microscopical Journal, London; Deutsche Klinick, Ber- 
lin ; Dental Cosmos, March, 1869; Correspondenz Blatt flir Zah- 
narzte ; Giornale di Correspondenza dei Dentisti ; Le Progres 
Dentaire. 



144 ARTIFICIAL ANAESTHESIA. 

after this lengthened exposure to the anaesthetic, when 
compared with the blood of another rabbit, which was 
not under its influence. This result induced me to ex- 
amine into the statements made by Dr. Sansom, relative 
to the action of anaesthetics on the blood-corpuscles, in 
his highly interesting and able work on chloroform.* 

Prior to giving a description of my experiments in 
this direction, it may be proper to briefly refer to the 
prevalent theories on the physiological action of anaes- 
thetics ; also to the experiments performed and conclu- 
sions arrived at by Dr. Sansom. The view generally 
entertained is that first suggested by Flourens, that 
these agents act directl} 7- upon the nerve centres, pro- 
ducing regular and progressive modifications in the 
functions of the brain and spinal axis, first affecting the 
cerebral hemisphere, then the power of co-ordination in 
the cerebellum, then the conduction of sensation and mo- 
tion in the spinal cord, and lastly, if the agent is pushed 
so far as to decidedly impress the medulla oblongata, 
suspension of respiration and circulation. 

Dr. John Snow, regarding this theory as erroneous, 
and recognizing ether, chloroform, and other anaes- 
thetics as non-supporters of combustion, advanced the 
theory that these agents, interfering with the introduc- 
tion of oxygen into the system, induced their effect by 
the suspension of oxygenation; he therefore asserted 
that u narcotism is suspended oxygenation." This view 
is embraced and strongly advocated by Dr. B. W. Rich- 
ardson, and in England apparently is being very gene- 
rally adopted by writers on this subject ; Dr. Kidd is, 
however, a prominent exception. 

Dr. Sansom, accepting this theory, and knowing that 
nitrous oxide is not only an anaesthetic but a supporter 
of combustion, recognized the necessity of presenting 
something more conclusive in the support of the view 
than had heretofore been offered. He therefore, in a 
paper read before the Royal Medical and Chirurgical 
Society, in 1861, as the result of certain experiments 
performed on the blood-corpuscles of man and animals 

* Chloroform, its Actions and Administrations. By Arthur 
Ernest Sansom, M.B., London : Lindsay & Blakiston, Philada. 



ANESTHETICS ON THE BLOOD-CORPUSCLES. 145 

out of the bod} r , attributed the influence exerted by 
anaesthetics on the nervous system to their acting 
direct^ upon the blood-corpuscles, by modifying their 
form and integrity, and indirectly upon the nervous 
system through this altered condition of the blood, 
by interfering with its oxygenation. In this work 
he describes a series of six experiments ; placing on 
glass slides, under a quarter-inch object-glass, hu- 
man and frog's blood, and subjecting them to the 
direct contact of alcohol, ether, and chloroform, which 
resulted quickly in the disintegration of the blood-cor- 
puscles, leaving nothing but their nuclei and debris 
of the walls of the corpuscles. From these experiments 
on blood out of the body, he states in the work referred 
to : M The effect, therefore, of these agents upon the blood 
is solution — destruction. At first there is a change in- 
duced in the cell itself and upon the nucleus (in the case 
of frog's blood). The globulinc of the blood is acted 
upon as it were by a caustic. Finally the blood-corpuscle 
is destro} T ed and the coloring matter set free." . . . 
From the foregoing facts and other considerations, the 
author considers that certain conclusions in regard to 
the action of anaesthetics are warrantable. Anaesthetics 
are agents which, when absorbed into the circulation, 
exert an influence upon the blood. Thej r are shown to 
have the power of altering its physical character and 
physical properties. By an action upon its constituent 
(proteinous) elements, they tend to alter and by a pro- 
founder action to destroy its organic molecules. Its 
physical perfection being interfered with, its function is 
held in abeyance ; the changes which contribute to con- 
stitute perfect life are retarded. Narcosis ensues ; and 
is due, not to the influence of a circulating poison, but 
to the influence of an altered blood. Further on he 
adds : " Narcotism (or to speak more particularly, chlo- 
roform narcotism) is due not to a special poison that 
4 mounts up to the brain,' but to an altered blood. Then 
4 narcotism is a suspended oxygenation.' Whatever 
produces, to a certain extent, insufficient aeration of the 
blood, produces narcosis; and whatever produces nar- 
cosis, produces, by some means or other, imperfect aera- 
tion of the blood." 
13 



146 



ARTIFICIAL ANAESTHESIA. 



Fig. 20. 



In drawing these conclusions, of an altered condition 
of the blood, from appearances presented by the blood 
out of the body, Dr. Sansom evidently leaves it to be in- 
ferred that somewhat if not exactly analogous results 
are produced on the corpuscles in the body, when human 
beings or animals are under the influence of anaesthetics 
by inhalation. After a patient, oft-repeated series of 
experiments performed by me during the past three 
months, not only on blood out of the bod}', but also in 
cases in which human beings and animals have been 
placed under the influence of ether, chloroform, and 
nitrous oxide, and the blood drawn from them prior to 
and after the administration of these agents has been 
carefully examined and compared, the results obtained 
compel me to take very decided exceptions to such con- 
clusions being justifiable in the premises. 

First Series. — The experiments were as follows : In 
m} r examinations of the blood of man and animals, when 

ether and chloroform Mere 
brought in direct contact 
with it out of the bod}*, under 
a fifth objective, the dis- 
charge of the nuclei and the 
disintegration of the corpus- 
cles have invariably occur- 
red, and in the frog leaving 
a result similar to that which 
is presented in the accom- 
panying drawing (Fig. 20) 
from one of my specimens, 
wherein it will he observed 
that the field is occupied by 
the nuclei, debris of disinte- 
grated globuline and cor- 
puscles, in which the change 
of form, size, and other characteristics are most striking. 
Second Series. — On placing, however, two glass slides 
containing frog's blood over watch-crystals, one holding 
chloroform and the other ether, and covering them with 
glass finger-bowls for half an hour, thus exposing one to 
an atmosphere of ether, and the other of chloroform, I 
found, on removing the bowls, and permitting the bloody 
sides of the slides to remain downward, until all the 




Frog's blood placed upon the slide, 
and chloroform brought in direct 
contact with it. 



ANESTHETICS ON THE BLOOD-CORPUSCLES 



147 



Fig. 21. 



ether and chloroform had evaporated, that no disinte- 
gration or marked change in the form of the corpuscles 
was observable under the microscope, on comparing 
them with the blood of a frog unaffected by an anaes- 
thetic. This forcibly demonstrates the difference be- 
tween exposure to direct contact and the vapor of chloro- 
form or ether, even out of the body. 

Third Series. — Over and again in the presence of a 
number of gentlemen, I have placed frogs under the in- 
fluence of ether, chloroform, and nitrous oxide, and ex- 
amined their blood-corpuscles immediately after without 
finding any disintegration or change in the form of the 
corpuscle. In one instance, a frog was so completely 
narcotized by chloroform that it died ; the thorax of the 
animal was opened, the lungs cut out, and the blood 
obtained directly from that 
organ, and even here, where, 
if the inference of an altered 
blood was correct, there 
should have been discharge 
of nuclei, disintegration, or 
marked change in the form 
of the corpuscle, nothing of 
the kind was evident, as will 
be seen by the accompany- 
ing illustration, drawn from 
the slide on which the blood 
was placed. (Fig. 21.) As 
already intimated, the ex- 
periments in this direction 
have been prosecuted on 
every available occasion 

within the past few months ; and I have not confined 
nn T self to frogs, but, in the course of vivisections on a 
large number of animals (rabbits, dogs, cats, and 
pigeons), to illustrate my course of lectures on physio- 
logy this winter, when these animals have been placed 
under the influence of ether or chloroform, their blood 
has been examined and no change in the form of the cor- 
puscle has been evident. 

Fourth Series. — The examination of the blood of a 
number of human beings, drawn prior to and after having 
been under the influence of ether, chloroform, or nitrous 




Corpuscles from the lungs of a frog 
which died under the influence of 
chloroform. 



148 



ARTIFICIAL ANESTHESIA. 




Corpuscles of a patient under the 
influence of chloroform. 



Fi#. 22. oxide, has yielded similar 

results, as will be evident 
from the accompanying illus- 
tration of the blood, obtained 
from a patient (Fig. 22) while 
under the influence of chloro- 
form. Anyone accustomed 
to microscopical examina- 
tions will recognize the nor- 
mal characters of the cor- 
puscles, so far as it is possi- 
ble to present them in a wood- 
cut. 

In conclusion, although it 
is not my intention in this 
communication to engage in an extended inquiry relative 
to how anaesthetics produce their effects, it seems to me 
that the above experiments demonstrate that we are not 
warranted in denying that these agents act directly upon 
the nerve centres. All the phenomena, indeed, attendant 
upon their administration, the gradual exaltation of the 
cerebral functions followed by the progressive impair- 
ment and temporary suspension of the special senses, 
the loss of co-ordination on the part of the cerebellum, 
and when the agent is pushed too far, the arrest of respi- 
ration and circulation through the decided impression 
made upon the medulla oblongata, seem to favor this 
hypothesis, in contradistinction to the theory that anaes- 
thesia is due to suspension of oxygenation. 

Experiment* with Nitrous Oxide by Drs. McQuillen, 
Thomas, and Turnbull) December, 1 877. — A large-sized 
frog was placed under a glass jar holding five quarts of 
nitrous oxide, and kept there sixteen minutes. With the 
exception of some change in the color of the skin, there 
was no apparent impression made the first five minutes, 
as be jumped about when the jar was moved in the pneu- 
matic trough. After that he assumed the position of a 
frog sitting on a log, and maintained it until removed 
from the jar, when he was found in a semi-torpid state 
with the eyes wide open. On touching the eyes gently, 
the lids closed, and then opened immediately ; the leg 
was retracted on pricking it with a pin. Two minutes 



ANESTHETICS ON THE BLOOD-CORPUSCLES. 149 

after removal from the jar, lie moved slowly about the 
floor, and ten minutes later hopped from a table on to 
the floor. After remaining out for thirty-five minutes, 
he was again placed under the jar, in a fresh supply of 
gas, and kept there for thirty minutes ; on being removed 
he presented the same semi-torpid condition, and re- 
covered from it in two minutes. In twenty minutes he 
was a third time placed in fresh nitrous oxide, and re- 
mained there fifteen minutes, with the same results as the 
previous trials ; the confinement for one hour, in all, to 
the influence of nitrous oxide not having made any 
marked impression on him. Examined under £ objective 
and B. eye-piece, the blood-corpuscle presented no dis- 
integrative discharge of nuclei, or change of form. 

A small-sized rabbit was kept under nitrous oxide for 
two minutes, and in one minute after was completely 
restored to consciousness. He was then kept under the 
gas for five minutes consecutively, and recovered in 1J 
minutes. Alter this, for twenty minutes off and on, the 
animal was under the influence of the gas. In three 
minutes after removal from it he was running around the 
room as though nothing had occurred. The blood ex- 
amined under the microscope gave no evidence of disin- 
tegration of the blood-corpuscles. 

To test the quality of the gas used, Drs. Turnbull, 
Thomas, and McQuillen inhaled it, and each one was 
sensibly affected by their inspirations of it. 

If we assume that the influence of anaesthetics is de- 
pendent not upon a direct action on the nerve centres, but 
upon an altered condition of the blood and the suspen- 
sion of oxygenation, we must apply the same principle 
to all diffusible stimulants. 

It will be noticed that it was in 1868 Dr. McQuillen 
published his experiments upon nitrous oxide. On the 
7th of December, 1869, Dr. Jeannel read a paper* before 
the French Academ}' of Medicine on the protoxide of 
nitrogen or nitrous oxide as an anaesthetic agent. He 
states that there is no record of a fatal case from the 
use of the drug, notwithstanding its frequent applica- 
tion. He reported a number of careful personal experi- 

* Uaz. Hebdomadaire, 1869, p. 786. 
13* 



150 ARTIFICIAL ANAESTHESIA. 

ments. He dwells at some length upon the rapidity 
with which the effects of tnis drug pass away, followed 
by the proper exercise of the natural functions, and 
concludes that his own and M. Limouzin's experi- 
ments authorize the presumption that this gas is an 
anaesthetic much less dangerous than ether or chloro- 
form. 

In August, 1870, Dr. Robert Amory published a number 
of experiments on man and animals* to show the physi- 
ological action of nitrous oxide. He commences his ex- 
periments with this proposition : — 

" I have not, as yet, been able to find how the peculiar 
effects of this so-called anaesthetic agent are explained ; 
nor has any one directly stated that the action may be 
explained by an accumulation of carbonic acid in the 
blood. A direct proof of this supposition it would be a 
difficult matter to give. An approximate idea I have 
attempted to show by a few experiments." 

After making his experiments, which he gives in a 
table at page 13 (see pamphlet), be observes: "Now if 
we examine this table carefully, we should merely com- 
pare the figures in the last column with each other, as 
also the effects produced by this agent upon the same 
animal. If we do so, we shall find that the gas dimin- 
ishes the amount of carbonic acid exhaled by almost 
one-half. This, then, would lead us to suppose that the 
effects produced by inhaling this gas may be due to the 
accumulation of carbonic acid in the blood; but a plau- 
sible explanation is that the oxygenation of the blood is 
prevented, and carbonic acid, the result of combustion, 
is withheld; the effects are by no means so rapid as when 
this agent is inhaled. Again, I do not quite accept a 
theory which supposes that an accumulation of carbonic 
acid in the blood will cause asphyxia and death in 
twent}' minutes." At page 18 there is a paragraph 
which strongly corroborates Dr. McQuillen's experi- 
ments. u Two or three times it has happened to me, 
when I had thought an animal dead from asphyxia, alter 
the inhalation of this gas, to be surprised by voluntary 

* New York Med. Journal, August, 1870. Republished by 
James Campbell, Boston, 1870. 



ANAESTHETICS ON THE BLOOD-CORPUSCLES. 151 

respiration recurring after I had removed the muzzle. 
In fact, 1 have now two dogs alive who have not respired 
for one whole minute several times when undergoing an 
experiment. Never has an animal died unexpectedly, 
and it was always very difficult for me to cause asphyxia, 
if the smallest modicum of air passed into the lungs." 

At page 29 the author finally states: "Having pro- 
ceeded thus far in my writing, I came across, acciden- 
tally, a lecture of Professor George Johnson, in the 
number of the Medical Times and Gazette for April 3, 
1869. 1 was exceedingly surprised to see a confirmation 
of his theory in regard to the anaesthetic action of 
nitrous oxide. What he had arrived at by careful reason- 
ing, I have been able to obtain by actual experiment. 
For example, he says : — 

'Nitrous oxide is a rapidly-acting anaesthetic, caus- 
ing complete unconsciousness in less than a minute. At 
a high temperature it is an oxidizing agent, but at the 
temperature of the bod} 7 it gives up no oxygen, but is 
exhaled again unchanged. When inhaled in place of at- 
mospheric air, it rapidly replaces the oxygen of the 
blood, and, this being done, the functions of the brain 
are completely suspended, and there is a state of pro- 
found coma, which quickly passes off when air is again 
allowed to enter the lungs. . . There is no reason* 
to conclude that the inhalation of either nitrous oxide 
or nitrogen causes an accumulation of carbonic acid in 
the blood.' Before this, he says : ' To produce oxidation 
of the brain, there must be (1) a free current of blood 
through the capillaries of the brain ; (2) the blood must 
be duly aerated or oxygenized ; (3) the blood must be 
unmixed with any material which prevents or impedes 
the giving up of oxygen from the blood to the tissues.' " 

Then our author and experimenter says: — 

" If we accept these three rules for the preservation 
of the nerve functions, of course, if one be wanting, the 
nerve functions are suspended. Now the experiments 
XIV, XV, and XVI, taken in connection with the accom- 
panying sphygmographic traces (which are given), show 
an increase of capillary tension, with, as we should sup- 

* Vide Experiments Nos. I, IV, etc. 



152 ARTIFICIAL ANESTHESIA. 

pose, increased arterial pulsations ; but finally, arrest of 
capillary pulsation in the brain. At this stage anaes- 
thesia occurs. When the pulsation recommences and 
the tension falls, consciousness sets in. This effect, 
then, is a violation of Rule 1. Again, the blood having 
no oxygen to give up in the capillary system, there is 
a violation of Rule 3." 

We do not think either Dr. Johnson or Dr. Amory 
has proven his propositions by facts; the one resorts to 
theory alone ; and the other to supposition after experi- 
ments, by supposing an increased number of arterial 
pulsations, which is not proven, as the pulse before in- 
halation, is increased in frequency by the nervous ex- 
citement, and always decreases when the patient has 
begun to inhale the nitrous oxide. This fact has been 
recently proven by a large number of experiments. 

We are fully convinced by experiments on animals 
and man that when death occurs, it is the result of syn- 
cope, caused by a capillar stasis of the blood, and the 
true anaesthetic action was discovered by Flourens, that 
nitrous oxide acts directty upon the nerve centres, pro- 
ducing regular and progressive modifications in the 
functions of the brain and spinal axis, first affecting the 
cerebral hemisphere, then the cerebellum, and lastly, the 
medulla oblongata, with suspension of respiration and 
circulation. 

Mode of Action of Anaesthetics. 

We have alread} r given our own results and those of 
others as to how anaesthetics act under the several agents, 
viz. : chloral, ether, chloroform, and nitrous oxide. Their 
true action is still a subject of dispute, and I avail my- 
self of the recent investigations of Dr. C. Binz, of Bonn,* 
and of ileinrich Ranke to further illustrate this complex 
subject. Binz concludes an article on the officinal sleep- 
producing substances in the Archie fur Experimental^ 

* Elements of Therapeutics. A Clinical Guide to the Action 
of Medicine. By Dr C. Binz. Prof, of Pharmacology of the Uni- 
versity of Bonn. Translated from the Fifth German Edition. 
Wm. Wood & Co., New York, 1878. 



MODE OF ACTION OP ANAESTHETICS. 153 

Path. u. Pharm., by saying that these agents possess 
the power of producing a kind of coagulation of the sub- 
stance of the cerebral cortex, whilst other agents, though 
nearly allied to the former in chemical composition, do 
not possess this power. Morphia, chloral, ether, and 
chloroform possess, these latter maintain, a strong af- 
finity for the substance of the cortex of the brain in man, 
and when they are introduced into the blood thej' enter 
into combination with the cerebral substance, opposing 
or impeding the disintegration of the living substance, 
and thus rendering it unfit to discharge the functions 
required of it in the living state. In a paper on the 
subject in the Centralblatt, Aug. 25, 1877, Heinrich 
Ranke* observes that protracted study of the effects of 
anaesthetics has led him to very similar conclusions in 
1867. He has found that the action of chloroform, ether, 
and amylene on frogs first produces a condition in which, 
just as in poisoning by curare, no contraction can be in- 
duced in muscle by any kind of irritation applied to the 
motor nerves, though the muscular tissue itself reacts to 
direct stimulation, and the current in the nerve remains 
constant both in force and direction. In a later stage 
of the anaesthesia the muscular tissue itself ceases to re- 
spond to the most powerful induction currents, though 
its proper electro-motor force remains unweakened; and 
lastly, at a still more advanced stage, the whole muscu- 
lar tissue of the bod}' passes into a condition of rigor. 
He has further found that a solution either of albumen 
from the brain or of mj-osin from muscle in very weak 
salt and water is precipitated by the vapor of the three 
above-named anaesthetics, and that their power of pro- 
ducing muscle rigor in the case of muscle depends on 
the coagulation of the myosin. 

Additional experiments have lately been instituted by 
Ranke, which demonstrated that not only chloroform 
and chloral h3 7 drate, when injected into the arteries, 
caused rapid stiffening of the muscles, but that the same 
influence was exerted by ether, amylene, bromoform, and 
bromohydrate, whilst, when tannin, cupric sulphate, mer- 
cury chloride, ferric sulphate, or spirits of wine were in- 

* Translated in the London Lancet, Nov. 24, 1877. 



154 ARTIFICIAL ANAESTHESIA. 

jected, though strong fibrillar contractions occurred, 
and coagulation of the blood, followed by death, in no 
instance was rigor produced. Iodoform, indeed, appears 
to form an exception to the conclusion that the rigor- 
producing action of the anaesthetics is something pecu- 
liar to them, for it is not known to possess anaesthetic 
properties. If injected in solution in ether, rigor is im- 
mediately produced, but ether has itself a stiffening 
action on muscle. Nevertheless, Ranke thinks he can 
distinguish between the action of the iodoform, which is 
immediate and tense, and that of the ether, which comes 
on later and is less powerful ; and he attributes the fail- 
ure of iodoform to act as an anaesthetic to its insolu- 
bility merely, which, as it were, masks its proper action. 
Ranke was unable to find that solutions of morphia were 
able to exert any coagulating influence on muscle, either 
within or without the vessels. It may be asked what 
relation does the action of these agents on muscle bear 
to the process of anaesthesia, and in reply Ranke ob- 
serves that anaesthetization obviously cannot depend on 
such a complete coagulation as admits of no further 
change, since the effects produced by anaesthetic agents 
are but transitory. Rut it is very conceivable that an 
action which in its final stages leads to coagulation of 
albumen may, in its earlier stages, render, to a certain 
extent, fixed and immovable the albuminous molecules 
in the ganglion-cells of the brain, and afterwards in 
nerve and muscle, the effect passing off with the removal 
of the cause. 

This same hypothesis was maintained b}* the late 
Claude Bernard on similar grounds, several years prior 
to the publication of even that of II. Ranke. The editor 
of the Lancet adds: "It would have been exceedingly 
interesting if the view of ' Binz' to the effect that morphia 
acts also as a coagulating agent upon the ganglion cells 
could be corroborated, since, if such were the ease, it 
wound tend to show that the various kinds of anaesthe- 
tics act essentially in the same manner." 

The physiological action of nitrous oxide, as given in 
Binz's work by the editor, is as follows : " When inhaled 
pure it appears to produce anaesthesia by taking the 
place of the normal respiratory oxygen, and so prevent- 



MODE OF ACTION OF ANAESTHETICS. 155 

ing the proper oxidation of the nervous centres; for 
though it contains more oxygen than atmospheric air, 
this 0x3' gen is perfectly inert, and remains throughout 
in chemical combination with its nitrogen. The gas is 
taken up by the blood and circulates with it, but though, 
as proven by the spectroscope, it enters into combina- 
tion with haemoglobin, it does not part with any of its 
oxygen to the tissues, being expired as such unaltered. 
It does not, however, prevent the escape of carbonic acid 
from the blood, for if the expired gas be passed into 
lime-water, a precipitate of carbonate of lime is thrown 
down." The editor gives no authorities for his conclu- 
sions, so they will have to be received with caution. 

We would refer those interested to the following au- 
thorities, in part kindly furnished by Dr. Isaac Ott, of 
Easton, Penn., and from his recent work.* 

Chloroform. — Kussmal, Yirchow's Archiv, xiii. p. 289; 
Bottcher, Yirchow's Archiv, xxxii. p. 126 ; Hermann, Pfliiger's 
Archiv, 1866, p. 27 ; Bernstein, Schmidt's Jahrbuch, bd. cxlii. p. 
227 ; Bucheim u. Eisenmenger. Eckhard's Beitrage, v. 73 ; Du- 
meril et Demarquay, Archives Generales, 1848 ; Whestphal, Vir- 
chow's Archiv, xxvii. 409 ; Snow, on Anaesthetics; Hnsemann, 
Schmidt's Jahrbuch, bd. cli. p. 84; Hering n. Kratschmer, 
Berichte der Wiener Akademie, lxii. bd. ii. ; Knoll, Sitzb. der 
Kaiserlich Akademie der Wissen., 1873 ; Vierordt, Archiv f. 
Physiolog. Heilkunde, 1856, 269; Gosselin, Archives Generales, 
1848; Schienesson, Archiv d. Heilkunde, x. 37, 172, 225; Anstie, 
Stimulants and Narcotics ; Bernard, Legons sur les Anaesthe- 
tiques, et sur l'Asphyxiae; Nothnagel, Handbuch der Arznei- 
mittellehre, 1874 ; H. Kohler, Handbuch d. Physiolog. Thera- 
peutik, 1876; Dogiel, Reichert's Archiv, 1866. Several refer- 
ences will be found in the body of this work. 

Ether. — Bernard, Substances Toxiques, 413 ; Wettich, 
Schmidt's Jahrbuch, bd. cxii. p. 212; Hermann, Archiv f. Anat. 
u. Physiologie, 1866, 27. 

Nitrous Oxide. — Jolyet et Blanche, Archives de Physiologie, 
July, 1873; Thompson, Phila. Medical Times, Nov. 1873; Her- 
mann, Lehrbuch der Experimentellen Toxicologic, 1874. 



* The Action of Medicines, by Isaac Ott, A.M., M.D., for- 
merly Demonstrator of Experimental Physiology in the Uni- 
versity of Pennsylvania : Philadelphia, 1878, pp. 143-4. 



1F6 ARTIFICIAL ANAESTHESIA. 



Deaths from the Inhalation of Nitrous Oxide. 

We know only of one instance in this city of supposed 
death from this anaesthetic agent, and in this case it was 
subsequently discovered that one of the cork props, which 
had no secnring-string attached, was found at the post- 
mortem examination in the larynx of the patient. 

Second case. In June, 1872, in the Dental Cosmos, 
was an editorial by James W. White, M.D., on a death 
alleged to have resulted from the inhalation of nitrons 
oxide gas administered bj T Dr. Newbrough, of New York, 
at whose office the death occurred, and b} T whom the fol- 
lowing (summary) of evidence was made before the coro- 
ner's jury. The patient, a middle-aged lad}', desired the 
extraction of seven or eight front teeth, which were loose. 
Dr. N. advised that their removal would be so easy that 
an anaesthetic would be unnecessary; but the patient in- 
sisted that she could not submit to the operation without 
it. Dr. N. then procured a six-gallon bag of nitrous 
oxide gas ; but the patient seemed equall\ r fearful of 
anaesthesia as well as pain, and as soon as she had made 
the inhalation, rejected the bag and declared her willing- 
ness to have the operation performed without it. At 
sight of the forceps her courage again failed her, and she 
decided once more to try the gas. She took one inha- 
lation, and again rejected it. By this time so much of 
the gas had escaped from the bag that the doctor replen- 
ished it. Of this she took two inhalations, and peremp- 
torily refused to have anything more to do with it, de- 
claring her determination to submit to the operation. 
The teeth were then extracted. M Immediately," says 
the doctor, " she fainted ; her head dropping over side- 
ways." The face rapidly became livid, and finally pur- 
ple; respiration falling to about fifteen per minute. In 
about thirteen minutes, notwithstanding the prompt ap- 
plication of the galvanic battery and efforts to assist 
respiration, death ensued. 

Dr. Otis, summoned b} r Dr. N., arriving in about ten 
minutes after the fainting, testified that he continued the 
usual restorative treatment for forty-five minutes, when 
death ensued. At post-mortem , found no disease of the 
heart; brain perfectly exsanguined in every part; no 



FATAL INHALATION OF NITROUS OXIDE. 157 

fluid ill any of the ventricles; one lung was more en- 
gorged than the other, but healthy. As the testimony 
was veiy discordant in several particulars, we shall give 
only the conclusions of Dr. W., who carefully sifted the 
whole testimony : — • 

tk In view of tLese discordant theories, it may seem 
presumptuous to express an opinion; but the conviction 
of the writer, based on personal experience, repeated 
hundreds of times, as well as on observation and reflec- 
tion, is that nitrous oxide, when inhaled, acts primarily 
by a specific stimulant effect on the centres of innerva- 
tion (over-stimulation, and consequent depression, if 
continued), and secondarily by pre cent in g the ox3 T gena- 
tion of the blood. 

The various opinions held by different observers 
doubtless owe much of their diversity to the considera- 
tions of the phenomena presenting at different stages of 
the toxical influence of the agent. 

That the inhalation of nitrous oxide continued, pro- 
duces by some method of action, no matter what its pri- 
mary effect, progressive depression of vital functions, 
which tends to death, and in which the anaesthesia, or 
temporary unconsciousness sought, is a more or less 
clearty-defined step in the downward path, there is no 
doubt. 

Without discussing the processes of its manufacture, 
or the means by which its purity may be determined, or 
the best methods for its administration, suffice it to say, 
that immunity from danger can at the best be assured 
only by an intelligent and watchful guard, that its ex- 
hibition be suspended while yet the centres governing 
respiration and circulation are not too profoundly im- 
pressed. 

Of the case under discussion, the inference seems 
entirely justified, that death was not caused by nitrous 
oxide gas, for the simple reason (if the evidence can be 
relied upon) that not enough was inhaled to produce 
such a result on any theory of its action. Nor was there 
any fact established by the post-mortem to justify such a 
conclusion ; while the testimony renders it entirely pro- 
bable that the cause of death was nervous shock, from 
14 



15S ARTIFICIAL ANESTHESIA. 

dread of pain, and apprehension of fatal effects from the 
inhalation of an anaesthetic agent. 

It may be remarked, however, that an examination 
by the coroner as to the possible lodgment of an ex- 
tracted tooth in the air-passages would have eliminated 
that from the list of uncertainties. 

Death from Nitrous Oxide. — The following case is re- 
ported in the Medical Times and Gazette of April 7th. 
As it is of considerable importance, on account of the 
extended use of the anaesthetic, we quote it in full : — 

"An inquest was held last week, at Manchester, on 
the body of Mr. George Morley Harrison, aged fifty- 
three, a surgeon in good practice, and formerly lecturer 
on Medical Jurisprudence at the Manchester Royal 
School of Medicine, who died whilst under the influence 
of nitrons oxide gas, administered at his own request 
previous to haying a tooth extracted by a neighboring 
dentist. Mr. Harrison, it appears, being unnerved and 
excited, partly from the suffering he had undergone, and 
partly owing to the want of proper food, which the con- 
dition of his nioulh had prevented him from taking, in- 
sisted on the inhalation being pushed until he should 
snore, and — for, at any rate, part of the time — held the 
mouth-piece in his own hand, and inspired very vigor- 
ously. The first attempt at extraction was made before 
he was fully insensible, and was abandoned until more 
of the gas had been given. Eventually, however, two 
teeth were removed. The patient did not appear to be 
coming round properly after the operation, and the 
dentist, taking alarm, sent for medical assistance. On 
the arrival of a surgeon, Mr. Harrison was pronounced 
to be quite dead. At the post-mortem examination there 
was found some fat about the heart; the cavities on the 
right side were distended with blood, while those on the 
left side were empty. The lungs on both sides were 
gorged with dark blood. All the other organs were 
healthy. 

The jury came to the conclusion that the deceased 
1 died from syncope, during the administration of nitrous 
oxide gas for the extraction of teeth, whilst laboring 
under fattj- degeneration of the heart.'" 



FATAL INHALATION OF NITROUS OXIDE. 159 

Post-mortem in the above cane of Death from Nitrons 
Oxide* — " The examination of the body took place seven- 
teen hours after death. Rigor mortis was well marked, 
and there was considerable post-mortem lividity. There 
was a good deal of fat beneath the skin, in the omentum, 
upon the external surface of the heart, and in the usual 
localities. The heart and pulmonaiy artery were opened 
in situ. The right side of the heart was distended with 
fluid blood; the left side was empty. There were two 
or three slight patches of atheroma in the aorta, and 
upon one of the aortic valves. There was some little 
evidence of fatty changes in the slightly altered color 
and consistence of the walls of the heart. The coronary 
arteries were examined and found free from disease. The 
mucous membrane lining the trachea and bronchi was 
congested. Some mucus was found in these tubes, but 
no blood or other foreign body. There was distinct 
thickening of the aiyteno-epiglottidean folds and of the 
vocal cords. The lungs on both sides were gorged with 
dark fluid blood ; at the left apex there was an old fibrous 
cicatrix. The liver was enlarged, its tissue was very 
friable, and of a dirty yellowish-white color. The kid- 
neys were full of blood ; otherwise perfectly healthy. 
The bones of the -skull were of unusual thickness. The 
visceral arachnoid was thickened and opaque. On re- 
moving the brain a large quantity of cerebro-spinal fluid 
made its escape, and the cornua of the ventricles were 
found dilated. The brain-substance was healthy, and its 
vessels full of blood." 

In this sad case a most valuable life was sacrificed 
almost at the patient's own request. No man has any 
right to do as a patient desires, or allow him to be the 
judge of the quantity of an anaesthetic he should inhale, 
as a patient under such circumstances is not a competent 
judge. 

The following are some observations of that veteran 
chloroformist, Mr. J. F. Clover, on this interesting case, 
addressed to the editor of the British Med. Journal : — 

"Sir: In the Times of Good Friday last, there ap- 
peared a notice taken from the Manchester Examiner, 

* Medical Times and Gazette, April 28, 1877. 



160 ARTIFICIAL ANAESTHESIA, 

of a death under nitrous oxide gas. The following was 
the verdict of the coroner's jury : 'Died from syncope, 
during the administration of nitrous oxide gas for the 
extinction of teeth, while laboring under fatty degene- 
ration of the heart.' 

The details of so unusual an event would be highly 
interesting to the medical profession, to enable them to 
judge of the safety or danger of the anaesthetic used. To 
form a correct opinion, we should at least know how 
long the inhaler was applied, the order and manner in 
which the movements of the heart and respiration became 
affected, and what had been swallowed previously. 

The verdict was probably inaccurate in stating that 
the syncope occurred during the administration of the 
gas, as no symptoms of danger were noticed until after 
the extraction of the second tooth. 

The most probable explanation of this sad case is 
that the extractions were difficult, and that the patient, 
on recovering from the effect of the gas, was susceptible 
to l he shock of a severe operation ; and that this shock, 
and not the gas, was the cause of the syncope, which 
structural disease of the heart rendered fatal. Unfortu- 
nately, it appears that no third person was present, and 
wc cannot expect the necessary evidence from the ope- 
rator, whose attention was otherwise directed. 

Those whose opinions of the effects of nitrous oxide 
are formed by inferences from Keid's Experiments on 
Asphyxia, and some cases of cardiac distress, first com- 
plained of after inhaling gas, will blame the latter. 
Those who daily witness the continuance of the circula- 
tion, in spite of the blood being black from the gas, and 
the speedy and cheerful recovery from it, will conclude 
that so unusual a result must have depended upon the 
peculiarity of the patient, whose heart was found in a 
state sufficiently diseased to account for sudden death." 

As this work was passing through the press, my at- 
tention was called to the fatal results following the in- 
halation of nitrous oxide in the ease of Mr. Samuel P. 
Sears, the operator being Mr. Jose R. Bruuet, D.D.S. 1 

1 Dental Times, vol. i. \);\'j;c, 157, New York. 1804. See also 
Instructions in Nitrous Oxide, by Geo. T. Barker, D.D.S. 
Philadelphia, 1870, p. 5G. 



NITROUS OXIDE GAS AND ETHER. 161 



CHAPTER VIII. 

J. F. Clover's improved apparatus for the combined use of nitrous oxide 
gas and ether. On the prevention of accidents from their use, and 
how to treat them successfully. Dr. F. N. Otis, of New York ; his 
apparatus, and his opinions. Death under the administration of ni- 
trous oxide and ether. Sir Henry Thompson, of London ; successful 
use of these agents combined. Inhaler of Cotlman and Shurtleflf, of 
Boston, for the use of nitrous oxide or ether combined or for each. 
Dr. J. D. Thomas's experiments with this inhaler. Letter of defence 
of Codman and Shurtleff. Bonwill's method of anaesthesia produced 
by rapid breathing of atmospheric air. 

The Administration of Nitrous Oxide Gas 
and Ether. 

With the addition of sulphuric ether to nitrous oxide 
gas, operations of any duration can now be performed. 
The writer has received from Mr. J. F. Clover, F.R.C.S., 
the following interesting account of his improved appa- 
ratus for administering nitrous oxide gas alone or com- 
bined with ether. This apparatus was on exhibition at 
our Centennial Exposition, being deposited and made 
by Mayer and Meltzer, of London, and was emplo3 7 ed 
but badly managed in the Clinic of the University of 
Pennsylvania in a surgical operation: — 

"The apparatus consists of a thin bag, oval in shape, 
and fifteen inches long; at one end connected with the 
ether vessel, at the other with the face-piece. Inside 
the bag there is a flexible tube also connected with the 
face-piece and ether vessel. 

By turning the regulator (Re) the patient is made to 
breathe ether directly into the bag, or indirectly through 
the tube or ether vessel. 

When the letter G is visible, the way to the gasbag is 
open ; when the letter E is visible, the only way to the 
bag is through the tube and ether vessel ; so that the 

14* 



162 ARTIFICIAL ANESTHESIA. 

more the regulator is turned toward E, the more ether is 
given, and vice versa. 

The other vessel contains a reservoir of water to pre- 
vent the temperature of the ether becoming too low; 
this is to be kept full. 

The ether vessel is to be rather more than half filled, 
the precise point being marked against the glass gauge. 
A thermometer inside this gauge tells the temperature 
of the ether. Before using it, the vessel should be 
dipped into a basin of warm water, and rotated until the 
thermometer stands at about 68°. 

If the room be cold, and if the patient have thin 
cheeks and large whiskers, the temperature may be 73°. 
It is important that the face-piece should fit closely 
against the face. Those made lry Mayer, of solid 
leather framework supporting a collar of inflated India- 
rubber, are the best, but sometimes they require to be 
warmed before using. For giving nitrous oxide only, 
the regulator is turned to G. The stopcock of the ether 
vessel is closed. 

This vessel is hooked upon the strap round the neck. 
The strap is adjusted so that the ether vessel stands at 
a higher level than the face-piece. 

The gas being turned on by rotating the foot-key with 
the foot, the gas bag is kept filled as fast as it is emp- 
tied by the patient. When the latter breathes out, the 
supply of the gas is stopped; and after the bag is fully 
distended, the escape-valve opens, and allows the expired 
gas to escape. 

If the shape of the patient's face prevent the face-piece 
from fitting closely, the escape-valve should be closed by 
pressing it with tire finger. Enough gas will escape be- 
neath the face-piece dining the expiration ; but the bag, 
being slightly distended, will yield the gas so abundantly 
that no air will be drawn in at the same place during the 
inspiration. 

If ether is to be used without gas, the gas-tube should 
be taken off the ether vessel; the regulator should be 
turned to G, and the face-piece should be first applied to 
the face during an expiration, and be held rather closer 
during expiration than during inspiration. 

It is important not to oblige the patient to inhale after 



NITROUS OXIDE GAS AND ETHER. 163 

the bag is empty, because the barometric pressure of air 
on the ether being diminished, the vapor would increase 
in strength, and make the patient cough, or perhaps 
vomit. 

The regulator is gradually turned towards E, and thus 
the way is opened to the inner tube. The air breathed 
through it carries vapor from the vessel into the distal 
end of the bag. 

As soon as one-half of the air passes through the 
ether vessel, the vapor becomes strong enough to cause 
insensibility in about two minutes, usually without any 
coughing. As the movement of swallowing is excited 
by a too strong, although less pungent, atmosphere than 
is generally needed to excite coughing, it should be 
watched for, and the regulator slightly turned back if it 
occur. 

By far the easiest and least unpleasant way of getting 
a patient ready for a surgical operation is to use gas 
and ether combined, the gas being given pure during 
four or live respirations, and the ether gradually added 
as above described. 

The supply of gas should cease when the ether is 
turned on ; but if during the operation we have admitted 
so much fresh air that the patient seems conscious of 
the taste of ether, we ma} T , instead of increasing the 
ether, give a liberal supply of gas until the patient is 
tranquil. 

I find less sickness and less complaint of the taste of 
ether afterwards than wheu ether is used alone. 

In operations on the eye, the muscular twitching and 
panting character of the breathing during the first few 
minutes of insensibility are objectionable ; but if the 
operation be not commenced for five minutes, and the 
ether given as strong as it can be taken without excit- 
ing a cough, the patient begins to breathe stertorously, 
and now the face-piece may be removed every third or 
fourth inspiration, and as the stertor goes off, the e3 r e 
will become quite steady. 

I am, however, so well satisfied with a modification of 
my chloroform apparatus, by which I can give as much 
of ether or chloroform as I like, that when I have a 



164 ARTIFICIAL ANAESTHESIA. 

choice, I prefer using these for cataract operations, and 
for the ligature of deep-seated arteries, etc. 

With respect to vomiting, I think it most important 
that the patient should have an empty stomach, and pre- 
fer that neither food nor drink of any kind should be 
taken for from four to six hours beforehand. 

There is less sickness after operations if done before 
breakfast. 

In using this apparatus, as in using others, the breath- 
ing and the pulse should be kept under observation. 

Whenever we see a patient swallow, it is probable he 
is taking the vapor stronger than is necessary, and the 
regulator should be turned back slightly. 

If the patient cough violently, remove the face piece, 
and be sure that the apparatus has not been overheated, 
or filled with ether above the proper level. 

As soon as any muscular twitchings, like those of 
paralysis agitans, are seen, give about a fourth of an 
inspiration of fresh air, and do not keep the face-piece 
quite close to the face till the twitchings have nearly 
ceased. 

I have never seen any harm result from the condition 
which causes these movements. If air were not given, 
they would increase, and then stop; the respiration 
would become intermittent, and, some time after this, the 
heart would cease to beat. 

The fact that death may be produced if signs of 
danger are disregarded, applies to all anaesthetics. 

Whenever the breathing becomes jerking, sobbing, or 
intermittent, the face-piece should be removed, but ap- 
plied directl}' the breathing loses that character, unless 
the pulse is much depressed. 

It is much less important to watch the pulse whilst 
giving gas and ether than in giving chloroform; but it 
is desirable, for when it decidedly loses power, we may 
safely admit a little fresh air, and thus anticipate the 
need of removing the face-piece to a greater extent on 
account of muscular twitching or stertor. 

If the finger be taken from the pulse to do something 
else, I would give a little air, unless the patient had only 
just begun to inhale, or was evidently but slightly under 
the aiuesthetic. 



NITROUS OXIDE GAS AND ETHER. 165 

Practical suggestions : — 

As the apparatus would be injured by an excited pa- 
tient taking hold of it, it is as well to have an assistant 
near in case of need. 

It is a good plan to replace a handkerchief over a 
patient's eyes, and keep it there until he is asleep, and 
apply it again when he is about to awake. 

In operations on the rectum, it is desirable that the 
bandage required for keeping him on his side should be 
applied before giving the gas. 

Sudden distension and bursting of the gas-bag or gas- 
tube can scarcely happen when the gas-rarefier is used ; 
but if this be not used, or if the gas-bottle have become 
frozen, it is desirable to warm the bottle, and in doing 
so, the top end should be more warmed than the other. 

Whenever there is much difficulty in getting the face- 
piece adjusted, it ma} 7 be necessary to arrange a hand- 
kerchief or tow 7 el so that the air drawn in under the 
face-piece may be nearly the same as that which was 
breathed out. 

In conclusion, the advantages of the apparatus are 
these : — 

1. It lessens the waste of ether, and consequently the 
odor of ether about the house. 

2. The patient usually goes to sleep without any 
struggling, and is ready to be operated on in from one 
to two minutes. 

3. The percentage of ether need not be so high as to 
produce coughing or swallowing, and it can be made 
stronger or weaker, as w r e wish, b} r merely turning a 
regulator. 

Lasth T , patients recover rapidly, with less delirious 
excitement, and less sickness, than if ether be given in 
the usual way." 

In April, 18?7, Dr. F. N. Otis, of Xew York, exhibited 
Clover's apparatus for administering ether and nitrous 
oxide, and remarked that it had given him the best satis- 
faction of any apparatus he had ever employed, for 
anaesthesia was readily produced without a struggle 
upon the part of the patient. It could be used for the 
administration of laughing-gas without producing any of 
that dreadfully suffocative appearance so commonly at- 



166 ARTIFICIAL ANAESTHESIA. 

tending its use by the methods usually employed. He 
thought well of prefacing the ether b}' the use of a mode- 
rate amount of nitrous oxide. 

Death under the Administration of Nitrous Oxide and 
Ether. — " A death has recently taken place in London at 
University College Hospital during anaesthesia from ni- 
trous oxide gas and ether, being, we believe, the first fatal 
case which lias occurred in this country that can be attri- 
buted to this combination of anaesthetics. The patient was 
a woman fifty-five years of age, who was admitted to the 
hospital in consequence Of strangulated femoral hernia. 
When admitted she was in a very weak and exhausted 
condition from constant vomiting, the hernia having 
been strangulated for over forty-eight hours. She was 
taken into the operating-theatre, and gas and ether ad- 
ministered by means of Clover's apparatus. In about 
four minutes she was well under the influence of the an- 
aesthetic, without having exhibited any previous excite- 
ment. Taxis was then applied, when almost immedi- 
ately the patient became pale and recommenced vomiting 
stercoraceous matter. At the same time the respirations 
became weak, and the pulse at the wrist imperceptible* 
The doors and windows of the theatre were at once thrown 
open, and artificial respiration was carried on for a few 
minutes. As no obvious benefit resulted, an enema, con- 
taining three ounces of brandy, was administered. Fumes 
of strong ammonia were applied to the nostrils, and am- 
monia injected into the right median basilic vein, but all 
without any good result, and the patient died within 
about ten minutes from the onset of the alarming symp- 
toms. At the autopsy, stercoraceous matter was found 
in the trachea and right bronchus. The right side of 
the heart and the large veins were full of dark fluid blood. 
The ventricular walls were thin and flabby, and the cavi- 
ties slightly dilated. The left ventricle was empty. The 
arch of the aorta presented numerous patches of athe- 
roma."* 

Sir Henry Thompson recommends Mr. Clover's plan 
of administering nitrous oxide gas for thirty seconds 
and then ether.f This is nothing but an attempt not to 

* Med. Times and (iaz., March 17, 1877. 
f London Lancet, .Jan. 8, IHTO. 



INHALER FOR NITROUS OXIDE AND ETHER. 167 

give to ether all the credit of being a perfect anaesthe- 
tic when employed for long and painful operations like 
lithotripsy. 

Inhaler for Nitrous Oxide G-as or Ether of 
Codman & ShurtlefF, of Boston. 

I have received a beautiful inhaler from the above firm, 
through the politeness of S. S. White & Co., of Phila- 
delphia. 

The points for which they claim superiority are : — 

" 1st. Durability ; being made of metal, they are not 
liable to be easily broken, as so frequently happens to the 
hard-rubber inhalers, and, as they are nickel-plated, they 
retain their brilliant polish without change. 

2d. For convenience both to the patient and opera- 
tor. With one hand the latter can apply the inhaler, and 
open or close the two-way stopcock, leaving the other 
hand at liberty to control the patient, or for such exi- 
gencies as may occur. As the elastic hood covers both 
nose and mouth, the patient is saved the necessity of 
having the nostrils closed either by clamps or the fingers ; 
a part of the operation always very disagreeable, and, 
to very sensitive patients, positively frightful, as it pro- 
duces a feeling of suffocation. 

3d. Cleanliness. The rubber hood, which alone 
comes in contact with the face, is easily removed and 
replaced, and, as all the other parts are either metal or 
hard rubber, the whole instrument can be kept perfectly 
pure by washing, which is a point of great importance 
to the comfort of the patient. 

4th. Durability and accurate working of the valves." 

Upon this, perhaps, more than anything else, depends 
the successful administration of anaesthetics. If the ex- 
haling valve does not quickly and perfectly close while 
the gas is being inhaled, air is taken with it, and the gas 
is so much diluted that it very much delays or wholly 
prevents the desired effect. 

If, on the other hand, the inhaling valve does not work 
properly, the patient breathes back into the reservoir a 
mixture of nitrous oxide and air. 



163 ARTIFICIAL ANESTHESIA. 

Fig. 23 is the inhaler with a hard rubber mouth-piece, 

A. The metal hood, b, is used for nitrous oxide gas. 

Fier. 23. 




CO0MA.N 1 SMUKTLtff, 
BOSTON. 



Fig. 24 is the inhaler for nitrous oxide gas: a, metallic 
hood, containing, b, flexible rubber hood, covering both 




nose and mouth; c, exhaling valve; d, two-way stop- 
rock; I, packing, through which a silk cord passes; e, 
sliding joint, where J is detached to connect the ether 
reservoir; J contains the inhaling valve. 

Fig. 25. The inhaler arranged for using ether. This 
diners from Fig. 24 only in the addition of the hollow 
sphere, f, which contains a coarse sponge, on which the 
ether is poured through the opening, o ; ir, cover, closing 
the reservoir when not in use. This part is attached at 
the sliding joint, E, and will tit most inhalers made by 
Codnian & Shurtleff during the last three years. By 
this arrangement waste of ether, by evaporating, is pre- 
vented, and it is stated that less than half the quantity 
is required to produce or keep up anaesthesia. 



INHALER FOR NITROUS OXIDE AND ETHER. 1G9 

The operator also escapes breathing so much of the 
ether as he is compelled to do when using it from a 
sponge or napkin. 

Fig. 25. 




Experiments made with, the Inhaler of Codman & 
Shurlleff, Boston. 

First experiment with new inhaler, November 1st, 1876, 
with three patients, two males and one female. 

In each was tested the ether attachment: two were 
unable to make the valve act quickly ; in the third the 
operation of inhalation was a success, the exhaling valve 
acting with each respiration by a click. 

Nov. 2d. Second experiment, two females and one 
male. With the females the soft rubber covering for the 
mouth, nose, and face fitted admirabl} r ; with the male 
the rubber cover could not be made to fit air-tight, owing 
to his having a beard, but it worked more satisfactorily. 
If the distance from the ether supply and the mouth- 
piece is shortened, the ether passes much more rapidly 
in the case of a patient who is feeble. 

The exhaling valve should be screwed tightl}', else it is 
apt in handling to become loose and will drop out. 

Third experiment. Dr. Thomas has demonstrated that 
the gag was not suitable, for it should not project out of 
the mouth to prevent its perfect closure. Second, it did 
not fit into the teeth as that of his brother's form (a plug 
of wood or cork with two concave surfaces and a string 
attached in the centre). 
15 



170 ARTIFICIAL ANAESTHESIA. 

I have received the following reply from the makers 
to a report of my experiments. 

"Sir : We have received yours of the 3d. In regard to 
the fit of the rubber to the patient's face, we have had no 
complaints, except where the beard in male patients has 
prevented close contact, and in cases of children where 
the face is too small to fit the rubber. In the former 
class of cases the beard may be wet with water, or that 
failing, the mouth-piece used instead of the flexible face- 
hood, which is the plan to be pursued with children. 

We have adopted this style of face-hood in preference 
to the English pattern, that having an air-tube attached 
to the metal hood, as being as well or better adapted to 
a great number of faces and not liable to get out of order, 
as that is almost sure to do after but few months' use, 
and as being removable for cleansing or removal without 
any expense or delay. 

The Centennial Judges, who took ample opportunity 
to examine this inhaler, refer to it in the report accom- 
panying the award to us of the highest prize, in the fol- 
lowing terms, viz.: ' The novelty of design of the inhaler, 
perfection of its execution, and general suitability to the 
rapid and safe administration of anaesthetics.' " 

Dr. J. D. Thomas, who has had extended experience 
from 75,000 cases, and who with a few exceptions ex- 
tracts most of the teeth required by the other dentists 
of this city, has favored me with the following observa- 
tions on the use of the inhaler of Messrs. Cod man and 
Shurtleff, which I loaned him not only to lecture upon 
before the Philadelphia Dental College Class, but to ex- 
periment with upon four patients. 

" The inhaler possesses qualities which I have seen in 
no others for sale. Jt is convenient, and being nickel- 
plated does not corrode. 

The stop-cock is so constructed that a patient may 
breathe, and have the gas turned on to him unawares. 

The small size of the mouth-piece is an objection (but 
one that can easily be remedied when ordering the in- 
strument), as patients in most cases exhibit a strong 
desire to pull the lips away and get a little atmospheric 
aii-, in the hope to resist and delay the effects of the gas 
as long as possible. The covering to the lips is an 



bonwill's method op anaesthesia. 171 

objection, but this is removable at the pleasure of the 
operator. The aperture between the inhaling valve is 
too small to admit of a full free passage of the gas where 
the patient possesses large capacity. The opening of the 
tube is of good size, but the valve should be smaller. 
(This last objection I have no doubt will be obviated by 
the makers.)" 

Bonwill's Method of Anaesthesia. 

This little work would not be considered complete 
without some brief reference be made to the method for 
diminishing sensibility by rapid respiration proposed 
by W. G. A. Bonwill, D. D. S., of Philadelphia. It is de- 
scribed Ivy Dr. A. Hewson in the Philadelphia Med. 
Times, March 4, 1876. 

" You have, all of you, I have no doubt, experienced 
the effects of rapid and deep respirations, after violent 
running, or blowing hard to ignite a fire, especially the 
confusion of sight and bewilderment of mind. These Dr. 
Bonwill recognized many years ago, associated with 
numbness of sensient nerves, as dependent on the rapidity 
of the respirations. Pursuing the subject he has brought 
it to practical use in his profession — that of dentistry — 
in which he uses it constantly to diminish the sensitive- 
ness of dentine, and even to produce such insensibility as 
to allow of the extraction of a molar tooth without pain. 
Of the latter I have had a demonstration in mj- own 
family, which has led me to the study of the subject my- 
self, and w T ith the most gratifying results. I have used it 
in stitching wounds, in handling over-sensitive parts, and 
in probings and the like." He then relates the case of 
a medical gentleman who tried the experiment with suc- 
cess who had no recollection afterwards of a " pin stick- 
ing him, much less of its having been firmly imbedded in 
his flesh, as he found it when he had ceased the rapid 
respirations, and the anaesthetic effect had passed off." 

His second trial was upon a boy in the receiving 
ward of the Pennsylvania Hospital. The boy had 
fallen upon the ice an hour previously, and had sus- 
tained a severe injury of his left wrist. The doctor 
directed him at once to try the rapid respirations. This, 



172 ARTIFICIAL ANAESTHESIA. 

in two minutes and a half by the watch, caused some 
dizziness in the bo}''s head, when the doctor picked up 
the limb and moved it about with the utmost freedom, 
diagnosing a bad sprain of the wrist, and the absence of 
fracture. When the boy was recovering he took to cry- 
ing, on account, he said, of the dizziness and confusion 
lie had experienced. Nothing, remarked the doctor, 
could have been more satisfactory than this case in its 
results. 

Analgesic Effects of Rapid Breathing. 

Dr. Addinell Ilewson, of this city, communicates an 
interesting paper on the History of Nitrous Oxide Gas 
as an Anaesthetic, and on the Analgesic Effects of Rapid 
Breathing (Transactions of International Medical Con- 
gress, 1876). Our own experiments were negative, 
and in conversation with several of the most intelli- 
gent dentists and physicians of this city, they all pro- 
nounced that their experiments of rapid breathing pro- 
duced a certain amount of anaesthesia, but thought 
most of the results obtained by the distinguished sur- 
geon were owing to the impression that relief of pain was 
to be obtained by this certain method. 



CHAPTER IX. 



Ether, its locnl application in the form of spray. Rhigolene. Dr. Lnta- 
mendi's new method of utilizing the anaesthetic effects of ether sprny. 
Anaesthetic mixture of ether and camphor. Excision of cancer of 
the breast by scissor-cutting under ether spray. Extract of eucalyp- 
tus as a local anaesthesia in dental operations. Snow, ice. and salt. 
Carbolic acid. Sulphate of morphia applied to sound skin also when 
the epidermis has been removed. 

Local Anaesthesia and Anaesthetics. 

The method of local anaesthesia proposed by Dr. Ben- 
jamin W. Richardson is the one most generally adopted. 



LOCAL ANESTHESIA AND ANESTHETICS. 173 

The process consists in directing ether on a given sur- 
face of the body, the strongest, freed from alcohol and 
water, in minute division or spray, mixed more or less 
with atmospheric air. This is accomplished by means 
of a hand-spray, an article which has become very popu- 
lar in diffusing the various perfumed waters in a room. 
The apparatus consists of a bottle to contain the ether; 
through a perforated cork a double tube is passed, one 
extremity of the inner part of which goes to the bottom 
of the bottle; above the cork a tube connected with the 
bellows (a rubber bag) pierces the outer part of the 
double tube, and communicates by a small aperture at 
the inner end of the cork with the interior of the bottle. 
The inner tube for delivering the ether runs upwards to 
the extremity of the outer tube. 

When the two rubber bags or bellows are compressed 
by the hand, a double current of air is produced; one 
current descending and pressing upon the ether, forcing 
it along the inner tube, and the other ascending through 
the outer tube and playing upon the column of ether as 
it passes from the inner tube. Rhigolene, a product 
obtained by the distillation of petroleum, is also for 
local anaesthesia. It is the lightest of all known liquids, 
its specific gravity being 0.625; it boils at 10°. This 
local anaesthesia, which is produced by the evaporation 
of these volatile liquids, which produce intense cold, can 
be used with advantage in minor surgery. It should 
never, by these agents, affect a large surface. Nor 
should it be long applied, else it will freeze and destroy 
the tissue, so that the death of the part may take place. 

Dr. Letamendi* has discovered a new mode of utilizing 
the anaesthetic effects of ether spray. After applying 
Richardson's spray-producer for about two minutes, in 
which he employs perfectly neutral sulphuric ether, the 
skin has by this time become red, and is the seat of a 
disagreeable sensation of cold, but no sensation of burn- 
ing in the part. If at this moment an incision, eight to 
ten millimetres long, is made with a convex bistoury in 
the centre of the reddened part, not being carried deeper 
than the papillary layer of the cutis, immediately the 

* Archives de Physiologie, November, 1875. 
15* 



174 ARTIFICIAL ANAESTHESIA. 

incision is made there is suddenly produced an anaemic 
zone, which enlarges outwards from the point incised. 

If the spray is again directed for a few seconds on the 
part which has thus become anaemic, the region becomes 
perfectly bloodless and completely anaesthetic. The tis- 
sues, when cut, are like frozen fat, and have lost their 
elasticity. Around the white circle there is a zone, in 
which the anosmia is not absolute. The spray directed 
on this zone speedily makes the anemia and consequent 
amesthesia complete. The anaesthesia can thus be car- 
ried around or along a limb. 

The theory brought forward by Dr. Letamendi to ac- 
count for the effect of the slight incision is, that the cold 
produced by the ether causes relaxation, and conse- 
quently dilatation of the vessels. The incision produces 
a sudden reaction, which converts the extreme dilatation 
into extreme contraction. The practical advantage is, 
that anaesthesia is obtained without a prolonged appli- 
cation of the ether spray. 

A n cesth et ic Mixt u re. 
ty. Sulphuric elhcr, fjj. 

Pulv. caiuphone, 3iv.— M.. 
Dissolve. 

On applying the mixture for a minute or two to the 
part where a superficial operation is to be practised, 
local anaesthesia is temporarily produced. 

Excision of Cancer of the Breast by Scissor- 
cutting under Ether Spray. 

Dr. Benjamin W. Richardson writes on the subject 
in The La ncet as follows : — 

" At this moment, when the dangers of general anaes- 
thesia are so anxiously felt by the profession, the fol- 
lowing clinical facts ma} T prove of value. A lady, fifty 
years of age, consulted me in April last respecting a 
tumor in the left breast. The tumor had been present, 
and had at times been painful for a considerable period, 
but, as it remained of small size, she did not consider 
it of importance until this year, when it began steadily 
to increase in size. The nature of the tumor was suffi- 



ETHER SPRAY AS AN ANAESTHETIC. 175 

ciently clear. It was a hard scirrhus, of the size of a 
small hen's egg, loosely held in the gland, with no ad- 
hesions to the muscular structure beneath. The family 
history of the patient confirmed the diagnosis ; her 
mother had suffered from scirrhus of the breast. The 
diagnosis left no doubt respecting the proper mode of 
treatment. There could be no hesitation in advising 
that the abnormal growth, while it was yet easily mova- 
ble and removable, should be excised, and to this advice 
the patient gave a willing assent. But now the question 
of the administration of an anaesthetic came under con- 
sideration. The action of the heart of this ladj' was so 
intermittent and irregular, and the power of her heart 
was so reduced, that the slightest external impression 
influenced it in its motion. She belonged, in a word, to 
that population which is prone to die suddenly from 
chloroform and the other narcotic vapors. Under these 
circumstances I proposed to the patient that the tumor 
should be excised under local anaesthesia ; and, that the 
failure of the process, if failure should follow the recom- 
mendation, might fall upon me entirely, I performed 
the operation myself. 

I operated on the 8th of May last, in the following 
manner. The patient having been placed in a semi- 
recumbent position on a narrow couch, 1 directed Mr. W. 
Perkins, who very efficient^ 7 conducted the local anaes- 
thesia, to direct gently over the tumor a large spray of 
common ether, so as to chill thoroughly, but not to 
freeze the skin. I let him maintain this for a period of 
five minutes. Then 1 handed to him another tube and 
bottle for spraying over the already chilled part the 
light fluid called anaesthetic ether, a compound of ether 
of sp. gr. .120 with hydride of amyl. A few moments' 
application of this lighter ether was sufficient to render 
the w 7 hole of the breast frozen like a hard snowball. 
For a minute longer, that the deeper structures might 
become equally chilled, the spray was continued. When 
the structures were thus prepared, instead of using a 
scalpel for cutting, as in the ordinary way, I made the 
required incisions through the skin with a pair of small, 
strong, sharp, slightly-curved scissors. Commencing 
the incision by an angular cut at the outer margin of 



176 ARTIFIC AL ANAESTHESIA. 

the part to be excised, I carried the lower blade of the 
scissors deeply into the breast, with the edge of the blade 
everted. In this way I cut the lower flap; then, com- 
mencing at the same angle, I cut in the same manner the 
upper flap. The rapidity and ease with which these in- 
cisions through the hardened tissues were made 6truck 
me most favorably. The incisions were deep enough to 
enable me to grasp the tumor firmly with the left hand. 
I now laid down the ordinary sharp-cutting scissors, 
and with a pair of strong, slightly curved, tooth-edged 
scissors, I proceeded to cut on each side of the tumor 
until 1 could fairly lift it up; then, by a few strokes 
made with the same scissors underneath, I cleared it 
completely away. The operation lasted precisely three 
minutes, and was unattended, during the whole time, by 
the escape of blood. The diseased mass removed, 
I had the ether spray withdrawn, in order to see if any 
vessels would bleed during reaction from the freezing. 
There was a little oozing of blood, which quickly subsi- 
ded, and one artery was tied, both ends of the ligature 
being cut off close to the vessel. The wound, carefully 
cleaned with a soft, damp sponge, was closed; the edges 
of it were secured with five sutures ; a pledget of cotton- 
wool, charged with styptic colloid, was placed over the 
wound; and a lint-pad and firm bandage completed the 
dressing. The patient passed a good night after the 
operation. She was allowed to rise and go into the 
drawing-room on the following day ; and as she exhibited 
no rise of temperature beyond 99° Fahr., and that only 
for a few hours, and suffered from not one untoward 
symptom, the dressing was left untouched until the 13th 
of May, when, on removing it, the wound was found 
healed throughout its entire extent. The sutures were 
removed a few days later, when the line of incision was 
found fairly closed, without a particle of discharge or 
interruption of healing at any point. 

During the whole of the operation the patient did not 
utter a single expression of pain, and I ma}' here add 
her description of what she felt of the operation. The 
description was taken down by Dr. Piatt, who rendered 
me his most able assistance, from the patient, imme- 
diately after the operation, and it is repeated in her own 



ETHER SPRAY AS AN ANESTHETIC. 177 

words: 'During the application of the ether spray the 
local feeling was that of gradually becoming cold, as in 
frosty weather, just as when the hands go numbed, but 
there was no actual pain. Felt pressure when the scis- 
sors went into the tumor, and experienced a kind of jar, 
but did not feel anything like an incision, and, in fact, 
was not aware when the incisions were made. Felt 
nothing of the next part of the operation, but when the 
tumor was held up and divided by three long cuts, ex- 
perienced a feeling, not of pain, but as if the parts were 
put on the stretch or dragged ; did not feel the tying of 
the ligature, but when some small substance (a bit of 
loose fatty tissue) was cut off, felt again as if the parts 
were being stretched. When the sutures were introduced, 
felt the pressure whilst the flaps were being held to- 
gether, but was unconscious of the prick of the needle.' 

In all respects this operation was, as an operation, 
completely successful, and one other success followed it 
I did not expect. As the recovery from the excision 
progressed, the irregular action of the heart became less 
marked, and ultimately disappeared altogether. In the 
mouth of July this lady called upon me, and was found 
to be restored to perfect health. 

Soon after the recovery of the patient named above, 
another lady came under my care, who was suffering 
from a scirrhous tumor, situated a little above the right 
breast, towards the axilla. This tumor, as a small mass 
about the size of a hazel-nut, had been present for several 
years without undergoing change; but recently, upon 
the occurrence of a slight blow from a fall, it had com- 
menced to rapidly increase in size. It was now a firm 
and well-defined scirrhus, of the size of a pullet's egg; 
it moved with moderate freedom beneath the skin, but 
not without conveying a suspicion, which afterwards 
proved to be correct, that it was attached to the pectoral 
muscle. Over the centre of the tumor there was retrac- 
tion of the skin, and the nipple was slightly retracted 
towards it. The glands in the axilla were free. 

The diagnosis in this instance was sufficiently clear, 
and the practice of immediate removal of the tumor 
seemed to me positive. But again the question of the 
administration of chloroform or of some other anses- 



178 ARTIFICIAL ANESTHESIA. 

thetic vapor pressed for careful consideration. The pa- 
tient had been declared by one of her medical friends to 
be suffering from disease of the heart, and had been 
urged by him in the most forcible terms not to subject 
herself to general anaesthesia. Another medical friend, 
in less determinate but still serious expression of opin- 
ion, gave her similar advice. She herself had read of 
the danger she heard described, and her anxious dread 
alone was all but sufficient to preclude the administra- 
tion of any narcotic vapor. On examination of the 
heart, I found an exceeding feebleness of action, an ir- 
regular and often intermittent beat, and at the apex a 
soft systolic murmur. I suggested, under these circum- 
stances, the removal of the scirrhous tumor under ether 
spray, and on June 23, again very ably assisted 1)3' Dr. 
Piatt, I performed the operation. The steps of the ope- 
ration were much the same as those described in the 
previous history. For a few minutes an ether of a speci- 
fic gravity of 1035 was sprayed over the breast, then 
the light anaesthetic ether was used until all the part 
was completely solidified. This condition attained, I 
made the incisions with sharp-cutting scissors, separated 
the tumor by a few lateral divisions with the same scis- 
sors, and then raising it, cut it out from its deep con- 
nections by means of the curved tooth-edged cutting 
scissors. The growth in this instance was firmly at- 
tached to the pectoral muscle over a space the size of a 
florin, but I found no greater difficulty than a little de- 
lay in separating it, together with a layer of connective 
tissue, from its attachment. 

So far the operation was actually bloodless. I waited 
a brief period before closing the wound for perfect reac- 
tion to occur, and for observing if there were any hem- 
orrhage. With the reaction one small artery yielded 
blood, but the bleeding was instantly and effectually 
stopped by torsion. The edges of the wound were 
brought together with five silk sutures, and the styptic 
colloid dressing, with cotton-wool, a soft pad and band- 
age, was applied. 

This patient, like the last, bore the operation per- 
fectly. She felt no pain from the incisions, and although 
the deep dissection which was required to remove the 



ETHER SPRAY AS AN ANAESTHETIC. 179 

tumor from its attachment was felt as a severe drag or 
pull, it gave rise to no evidence of acute pain. The act 
of sponging the wound, and the insertion of one of the 
sutures, caused momentary expression of pain, but, on 
the whole, she was throughout brave, perfectly collected, 
and as quiet as if she had been asleep. This patient, 
like the previous one, progressed so favorably that she 
was allowed to get up every day. On the fourth day 
after the operation, as she complained of the pressure 
of the pad, I removed the dressing, and found the wound 
freshl} r healed throughout its entire length, without a 
trace of suppu ration. In this act, however, a little mis- 
fortune occurred. A portion of the cotton-wool adhered 
firmly, through the styptic colloid, to a loose end of the 
upper suture, and, while I was extricating the wool, an 
accidental movement of the patient caused the ligature 
to tear out of the upper lip of the newly-joined skin. 
From this slight point there flowed as much as a drachm 
and a half to two drachms of bright, red, very thin 
blood. I stopped this bleeding, not very readily, by 
firm pressure with stj-ptic wool ; but a little further 
bleeding took place during the da} r , beneath the com- 
press, and into the subcutaneous tissue, and gave rise to 
a superficial sore about the size of a sixpence. On the 
eighth day after the operation the patient was able to 
go out of doors, and, but for the slow healing of the 
small sore whence the hemorrhage proceeded at the first 
dressing of the wound, recoveiy rapidly succeeded. 

One other fact closely connecting this with the pre- 
ceding case is worth}* of particular notice. As this 
second patient began to rail}' from the operation, the 
distressing cardiac symptoms entirety passed away, the 
stroke of the heart improved in tone, the irritability 
ceased, and the faint murmur became imj)erceptible. 

The facts recorded call for one or two brief com- 
ments. 

The effect of the local an&sthesia. — It is certain that 
in both these cases the local method afforded everything 
that could be desired in the way of anaesthesia. It saved 
ail acute pain ; it saved the patient the dread of death 
during the insensibility from a general anaesthetic, and 
it enabled me to proceed in our task without a thought 



180 ARTIFICIAL ANiESTIIESIA. 

as to the immediate safety of the patient. I may say 
more for it still. It warranted me in recommending the 
operation. I should certainly not have advised any 
friend of mine, whose heart was in the same condition 
of irritability and irregular nervous supply, to inhale 
an anaesthetic vapor, to the fatal effects of which such 
conditions of the circulation are so favorable. Apply- 
ing then this same rule to a patient who in putting his 
life into my hands makes his life for the time mine, I 
should consider it actually wrong to recommend a risk 
I would not myself accept. But, taking advantage of 
the local method, 1 had no occasion to suggest a danger 
of any kind, while I secured my patients the benefits of 
anaesthesia. I saved them the dread of death from the 
effects of a general anaesthetic ; I saved them possibly 
the S3nnptoms of after- vomiting and faintness; and I 
saved myself and my colleagues during the operation 
the anxiety that ever attends the administration of a 
general aiuesthetic to persons in whom disease of the 
heart is foreknown. 

The method of cutting with scissors. — Local anaesthe- 
sia has many disadvantages. It is more troublesome 
than general anaesthesia as a detail of practice, and, as 
it leaves the consciousness alive, it fails at times in pre- 
venting the fears of the patient. But hitherto the 
greatest difficulty in operating under it has been the ob- 
stacle of cutting through the hard, frozen, insensible 
part. The resistance to incision by the best cutting 
knife, and especially to dissection by the knife, is such 
that I have seen the most skilful surgeons troubled by 
it ; and I have never been able to complain of the objec- 
tion that has been made to the method on this ground. 
The difficulty is now overcome by the process of scissor- 
cutting which I have here introduced. The advantage 
of the scissors over the scalpel will be at once proved 
by any one who will take a thick, firm structure, the 
cover of a book, for example, and try to cut through it. 
With the best of scalpels he will be troubled ; but with 
scissor blades he will cut with the utmost facility, if the 
blades be well set. So, in cutting through the frozen 
animal tissue, the parts can be divided as rapidly as ma} r 
be wished with the scissor blades, with perfect accuracy 



ETHER SPRAY AS AN ANAESTHETIC. 181 

of incision, and as deeply as may be desired. The cut- 
ting is also made without any downward pressure, by 
which pain of pressure is saved. Also in deep dissec- 
tion, the tissues, frozen as they are exposed, can be di- 
vided more easily than by the knife ; for the harder they 
are solidified, the easier thejr are divided by the scissor 
blades. In a word, I believe that every cutting opera- 
tion, in which local anaesthesia is practicable, may be 
performed neatly and effectively by scissor-cutting, and 
that a much larger number of operations may now be 
painlessly carried out under the local method. 

Some little attention requires to be paid to the instru- 
ments used. The scissors for superficial or skin cutting 
should be exquisitely sharp, neat, and strong ; and I 
prefer them slightly curved. For deep cutting, where 
there are many bloodvessels, the tooth-edged cutters are 
valuable. These pierce, crush, and divide at the same 
time, and they save blood. For other purposes, as for 
division of a sinus, some modifications are required, and 
Messrs. Krohne and Sesemann are now making for me 
a case of instruments for the special purpose of opera- 
tion in the method under consideration. 

Effect of the operation, on the heart, in the cases re- 
lated. — No fact is more instructive in the history of the 
patients recorded in this paper, than the beneficial effect 
produced on the functions of the heart by the operation. 
In both instances the cardiac irregularit}' and irritability 
were purely due to irregular nervous supply, to nervous 
irritation and consequent muscular exhaustion. The 
irritation might have been in part due to the mental 
anxiety which naturally accompanies the disease, or it 
might have been due to the irritation of the tumor, and 
have been reflex in character. Whichever view be cor- 
rect, the result of the operation was curative, and, as 
the cases are typical of a class of phenomena of disease, 
the lesson they teach is extended far beyond them as in- 
dividual illustrations. They show that so soon as the 
heart obtains rest from the persistent nervous thrill that 
invades it, its muscular tone returns, and its irregular 
motion and excitability cease. Thus by operating early 
for the removal of cancer, the surgeon acts as physician 
also, and prolongs the general life by removing the local 
16 



182 ARTIFICIAL ANAESTHESIA. 

disease. I aui convinced I have seen patients suffering 
from cancer, die from the mental and local irritation of the 
disease long before any development of the malady has 
advanced to kill Iry destruction of the part or organ in- 
volved. I infer, therefore, that if, without any danger 
to life from general anaesthesia, we can remove external 
malignant growths painlessly and promptly, so soon in- 
deed as they are detected, we shall bring art, effectively, 
to the defeat even of cancer." 



Extract of Eucalyptus. 

This agent is recommended as a local anaesthetic in 
dental operations and toothache. Apply one drop on 
cotton to the sensitive dentine just before excavating for 
filling.* 

Local Anaesthetics — Ice and Common Salt. 

Snow or pounded ice makes a most valuable local an- 
aesthetic, and by employing it in an elastic bag, like that 
of Chapman, it will be found of great utility in all su- 
perficial incisions. If the snow or pounded ice is mixed 
with common salt in alternate layers, and placed in a 
gauze bag, a more profound impression may, in from 
fifteen to twenty minutes, be produced, and the tissues 
can be completely frozen if permitted to remain for one 
hour, and even a deep-seated tumor can be removed 
without any pain from the knife. It is well to examine 
the operation of the mixture, as the parts may become 
frost-bitten. 

Alcohol. 

In the use of snow or ice there is more or less pain in 
the part until it is frozen. By substituting cold alcohol 
the parts can be immersed in it for a long time, so as to 
deprive them of ordinary sensibility, and, although the 
faintest touch can be perceived, cutting or pricking them 
can be well borne. 

* Boston Med. and Stirff. Journal. 



CHLOROFORM. 183 



Carbolic Acid. 

Carbolic acid if applied to the skin at first is painful, 
but after a time that passes away, and leaves the surface 
in such a state that even the white-hot iron can be ap- 
plied with impunity. 

In some instances, I have simply painted the parts 
with a strong solution, or, when I desired to make one 
long incision, a line was drawn with a brush, charged 
with the liquefied crystals of the acid. 

Morphia. 

When sulphate of morphia is applied to the skin, even 
in the solution, or three or four grains to the drachm, it 
has but little result in relieving pain ; but if the cuticle 
is removed, it then may be dusted over the surface with 
much better effect. 

Prof. Kdnig sa} T s that he has combined the hypodermic 
administration of morphia with chloroform in a large num- 
ber of cases with favorable results. It is seldom necessary 
to give more than from one-sixth to one-third of a grain. 

If a solution of sulphate of morphia, one grain to the 
drachm of water, be made, and one-fourth injected by a 
hypodermic syringe, under a part to be operated upon, 
it will produce local anaesthesia. 



CHAPTER X. 



An abstract of the employment of chloroform and ether, alone and in 
combination. Chloral hydras. Butylehloral in practical medicine. 

Chloroform. 

When a four per cent, solution of chloroform in at- 
mospheric air is administered by inhalation to a human 
subject, the first effect observed is acceleration of the 
heart's action, accompanied by contraction of the arte- 
rioles; the primary influence of chloroform being that of 
a diffusible stimulant upon the nervous centres. In the 
later stages of its operation, when the vapor accumulates 



184 ARTIFICIAL ANAESTHESIA. 

in the blood, entering the circulation more rapidly than it 
can be eliminated by the kidneys, the lungs, and the skin, 
a decided narcotic effect is produced, the frequency of the 
respirator}' act is reduced, the pulse loses in force and be- 
comes feeble, signs of deficient aeration of the blood appear 
in the livid color of the face and cyanotic lips, and finally 
the subject is rendered completely comatose, unconscious 
of surrounding objects, and is entirely insensible to pain. 
This state of narcosis or anaesthesia is attributed to two 
causes acting concurrently; first, a specific action ex- 
erted by chloroform upon the brain and medulla, and 
the origin of the pneumogastric nerves in the floor of 
the fourth ventricle, rather than by a direct influence 
upon the red blood-corpuscle, causing its contraction 
and interfering with its function as an oxygen-carrier 
to the tissues. As a consequence of this we may have 
death from respiratory paralysis, or, secondly, we may 
have the function of respiration so impaired as to lead 
to an undue accumulation of carbonic acid and marked 
diminution of oxygen in the blood ; and this same 
result ma} 7 be brought about by its second action pre- 
venting the normal absorption of oxygen by the red 
blood-corpuscles. A French physiologist, P. Bert, hav- 
ing declared that, when the amount of oxygen in the 
blood decreases to the amount of two or three per cent., 
narcosis is produced, it is seen that a plausible explana- 
tion of the anaesthetic effect is given ; but there are rea- 
sons for believing that, in addition to this indirect action, 
chloroform has some specific, soporific effect upon the 
nervous system, which is peculiar to itself, in this re- 
spect resembling opium and the other narcotics. Ex- 
periment, moreover, has shown that its administration 
produces anemia of the brain, differing in this respect 
from ether, where no such effect takes place. 

In chloroform-anaesthesia we notice a paralysis to a 
greater or less degree (1) of the sensory nerves ; (2) of 
motor nerves ; (3) of the function of organic life. 

Chloroform is classed as a catalytic by J. G. West- 
moreland,* and he recommends it in albuminuria from 
the fact that chloroform forms a gelatinous combination 
with albumen. 

* Acology and Therapeutics, p. 177. 



EXTERNAL USE OF CHLOROFORM. 185 

External Use of Chloroform in Substance or Vapor. — 
Chloroform is used in medicine both for its stimulant 
and narcotic properties, to increase force, subdue spasm, 
and relieve suffering". Given in large doses it abolishes 
pain and contraction, paralyzes muscle and nerve, pro- 
foundly depresses force, and leads to death. The largest 
amount of chloroform inhaled by one person was 112^ 
drachms in one day ; another took one pound in five 
days. According to " Stille's" Therapeutics (vol. ii. p. 
194), recovery has occurred after the swallowing of two 
ounces of chloroform. 

After the continuance of the habit of chloroform- 
taking, the following symptoms generally appear, in the 
following order: (1) sleeplessness of a most distressing 
character, and only to be overcome by abstinence from 
chloroform; (2) deafness; (3) apathy and disinclination 
to society and to conversation ; (4) tremulousness of the 
hands. 

Experience shows that frequent chloroform inhalation 
is like " dram-drinking." Its effects are similar to those 
of alcoholism, and it will produce symptoms resembling 
mania-a-potu. In the report of the committee of the 
Med. and Chir. Society,* it is stated that a man who had 
been accustomed to the use of enormous doses of chloro- 
form to relieve asthma, frequently inhaling forty drachms 
a day, was reported to have had this appearance " on 
admission to the hospital ; he seemed in a constant state 
of dulnessi or like a person intoxicated" 

Chloroform, by its wonderful power over pain and 
muscular spasm, has been employed by Dr. Gobrecht and 
others in cases of poisoning by strychnia, with decided 
success. Even should, as was proved by the late Dr. 
Anstie and others, it have no antidotal action, it is of 
great service in relieving the fearful suffering, reducing 
the pulse to its natural standard, and causing respira- 
tion to become more eas\r. Another important matter 
is that under chloroform- or ether-anaesthesia, the tetanic 
convulsions from the sti\ychnia are so controlled that 
nutritive enemata may be administered and retained. 

Chloroform is valuable in thei:reatment of acute ma- 

* London. 
16* 



186 ARTIFICIAL ANESTHESIA. 

nia, chorea, and convulsions, especially in children, also 
in puerperal convulsions ; it has proved to be an efficient 
remedy in our hands in procuring sleep. Tn cases of de- 
lirium tremens, in the reduction of hernia, and the diag- 
nosis of abdominal tumors, chloroform will be found most 
valuable. 

The late Dr. Snow relates an interesting case of a sci- 
entific man who became insane and refused to take food. 
It was found that if chloroform were given and food 
offered, during the waking stage, the patient would take 
it. Chloroform was, therefore, administered before every 
meal for a long period It has also been employed in 
the delirium of fever in cases where the patient has been 
worn out, in spasmodic diseases of the air passages, 
spasm of the glottis, laryngeal cough, spasmodic croup, 
and whooping-cough, when in very dilute vapor. 

Dr. Sansom has found great value from the use of 
chloroform in several cases of phthisis. The same au- 
thority states that in some cases of chronic bronchitis, 
in acute bronchitis, and in pneumonia, when danger may 
occur from stasis of blood in the lungs themselves, it is 
not advisable to employ chloroform by inhalation. In 
paroxysmal and violent cough, combined with morphia, 
gh'cerine, and water, it is often very beneficial; and in 
the early part of the treatment of asthma, thirty to fifty 
drops inhaled from a handkerchief relieve the spasm, 
induce narcosis, and prevent the paroxysms. 

Dr. Hyde Salter, the great authority. in the treatment 
of spasmodic asthma, sa} T s, "The inhalation of chloro- 
form is, beyond doubt, one of the most powerful methods 
of treatment of the asthmatic paroxysm that we pos- 
sess." Properly diluted, the vapor is not pungent, and 
instead of increasing any tendency to spasm, at once 
relaxes it. Dr. Salter has never seen any bad effects 
from chloroform administered in the height of a parox- 
ysm of asthma, and persons sound asleep ma}' be chloro- 
formed without their being awakened. A nyesthesia can- 
not, however, be produced in any one partially awake, 
or even lightly sleeping, without their knowledge. 

One of the secondary effects of the prolonged use of 
chloroform in asthma is an increase of the asthmatic 
tendency. The use of chloroform must no more be al- 



PREPARATIONS OF CHLOROFORM. 187 

lowed to become a habit than the use of opium. We 
have repeated this experiment in seven cases of asthma, 
and, although we felt some apprehension, still no disa- 
greeable symptoms presented themselves, and the pa- 
tient was relieved of the attack, but it returned, and, 
fearing its injurious influence, we substituted hydrate of 
chloral during the paroxysms, especially when unable to 
sleep. Patients vary in the benefit which they derive 
from chloroform. In some, small quantities not only 
relieve the urgent distress, but also prevent its recur- 
rence. The congestive chills of the South, or the cold 
stage of intermittent fever, may be shortened, so as to 
gain time for the introduction of quinine into the s} 7 stem, 
by the inhalation of chloroform. Dose, 20 drops, sprinkled 
on a fine net, permeable to the air, and repeated several 
times until the effect required is produced. 

In epilepsy, the inhalation of chloroform has been 
found valuable, especially in the treatment of injuries 
and fractures, the result of epileptic attacks. It will 
also be found useful internally in the same disease, in 
combination with the bromides of potassium, sodium, 
calcium, and iron, with or without strychnia. 

The following are a few of the preparations of chloro- 
form: — 

1. Tinctura chloroformi comp., B. P. (chloroform, rec- 
tified spirits, comp. tinct. of cardamon; 1 in 10). Dose, 
n^xx-lx; for internal use, to relieve pain and spasm. 

2. Linimentum chloroformi (chloroform ,*ij, camphor 
liniment ^ij, olive oil ^iv). 

3. Mistnra chloroformi (chloroform *ss, camphor pulv. 
gr. ix, yolk of one egg, water |vi). Add chloroform and 
camphor, rubbing them up well, then add the egg by 
degrees to form a nice mixture. Dose, a tablespoonful 
every hour. 

In neuralgia, a few inspirations of chloroform vapor 
from a towel or handkerchief (sometimes enveloped in a 
cone of paper, flannel, or metal, for convenience of ad- 
ministration and to regulate evaporation) will often re- 
lieve the severe pain, almost magically. If the suffering 
be not of a serious character, and the affection be mod- 
erate in its extent, the relief may be permanent. If the 
stimulant effect should be desired over a larger portion 



188 ARTIFICIAL ANESTHESIA. 

of the bocty, the following liniment can be employed 
with advantage: — 

I£. Chloroformi. f 3Jss. 

Pulveris camphora, gj. 

Spiritus terebinthinae, f £ss. 

Olei lavandulae, n\, xx. 

Olei olivse, f §ij. — M. 

The camphor to be broken in small pieces and dis- 
solved in the chloroform and turpentine; the olive oil 
should then be warmed and added gradually. Ointment 
for topical use in neuralgia: in the proportion of from 
5 to 15 of chloroform to 30 parts lard ; or by means of a 
speculum, the vapor of chloroform may also be carried 
into the vagina or rectum, remaining for ten minutes. 
Or we may use a mixture of equal parts of the chloro- 
form liniment, of the Pharmacopoeia, and the officinal 
camphorated soap liniment, for the same purpose. 

Powerful agents act on the skin more effectually when 
dissolved in chloroform, as they promote the cutaneous 
absorption, and the addition of an equal quantity of al- 
cohol hastens the process, so that when we desire to 
limit the anodyne effect to a small spot, we may apply a 
solution of camphor in chloroform, of equal parts by 
weight, or as a still more powerful sedative — 

fy. Morphia: sulphatis, gr. viij. 

Atropine sulphatis, gr. iv. 

Alcoholis, 

Chloroformi, aa ^ij. — M. 

S. To be applied with a camel's hair brush. 

These two agents might be added for facial and dental 
neuralgia : Ext. gelseminum* fl., gtt. iij every three or four 
hours ; croton chloral hydrate in pills, 3 grs. every three 
or four hours. 

This prescription, in facial or sub occipital neuralgia, 
should not be spread over a large surface at one time, 
as both the atropia and the morphia are more readily 
absorbed after this solution in chloroform. Strychnia, 
aconitia, or quinia may also be combined with chloro- 
form in a similar manner. A very good plan is to 

* The effects of this remedy should be carefully watched. 



VERATRI^E, MORPHINE, AND CHLOROFORM. 189 

cover a cup with linen and drop a portion of the 
chloroform or the mixture on its surface, and hold it in 
contact with the painful part for a few seconds, which 
will often produce a good result in pleurodynia or neu- 
ralgia of the chest wall. In more severe, general neu- 
ralgia, I have on several occasions been obliged to keep 
the patient gently under the influence of chloroform for 
a considerable time until the person obtains sleep, or 
the pain has been entirely relieved. If the neuralgia, in 
the form of hemicrania or sciatica, should be of malarial 
origin, we may resort at first to the following mixture: — 

fy. Yeratriae, gr. v. 

Morphiae sulphatis, gr. iij. 

Linimeuti chloroformi, f ^ij. — M. 
Fiat lotio. 

The part to be rubbed with this lotion during the 
paroxysm of pain, while two-grain pills of quinia sul- 
phas are given every hour until its physiological effects 
are produced. Cinchonidia maybe substituted in three- 
grain doses if the patient cannot take the quinia. 

This same treatment, in conjunction with quinine, will 
often relieve sciatica. In acute earache or toothache, 
two or three drops on a small piece of cotton- wool intro- 
duced into the ear or tooth will occasionally cause com- 
plete relief; if too large a quantity is used, it will cause 
redness, smarting, and even blister. Equal parts of 
chloroform and opium or creasote are also useful in 
toothache. When mixed with an equal quantity of cam- 
phor, it forms one of the most valuable agents to relieve 
the local pain of sprains, etc. In cancer, where the skin 
is broken, leaving a foul and irritable sore, the surface 
may be deodorized and the pain temporarily relieved by 
the use of the hand-spray playing the vapor on the raw 
surface. The pain of other forms of cancer, such as of 
the os uteri, rectum, and mammary gland, may be also 
relieved by application of the same agent. In the pho- 
tophobia of scrofulous ophthalmia, a few drops of chloro- 
form held in the palm of the hand, close to the irritable 
eye, will cause the child to bear the light with less pain. 
In the itching of the ear, nose, and rectum, in which we 
have urticaria, lichen, or prurigo, the annoyance may be 
allayed by the use of an ointment composed of half a 



190 ARTIFICIAL ANESTHESIA. 

drachm of chloroform to an ounce of lard (it must De 
kept in a ground-stoppered bottle). 

Pruritus Vulvae. — In this most persistent, trouble- 
some, and annoying disease, we have found chloroform 
useful in combination with carbolic acid and soap lini- 
ment, as follows : — 

R. Acidi carbolici, git. xii-xxiv. 

Chloroforrai, f ^ij. 

01. olivoe, 

Linimenti saponis, aa f 31J. — M. 
Apply with a soft sponge to the affected parts. 

Internal Use of Chloroform. 

Chloroform has been found extremely valuable in all 
cases of colic, and will often assuage even pain of colica 
pictonum ; this is due to its local anodyne and stimulant 
carminative action. In flatulent distension of the stomach 
equal parts of chloroform and camphor will be found 
beneficial. In diarrhoea, after the removal of the irri- 
tating agent, equal parts of chloroform and alcohol with 
a portion of the tincture of opium and capsicum may be 
administered with great benefit. In insomnia, where 
pain prevents the patient from sleeping, the following 
mixture will often prove useful: — 

R. Morphine muriatis, gr. iss. 

Alcoholis 

Chloroformi, aaf.^ss. 

Tr. cardamorni compos, f 3jss. — M. 
A dessertspoonful at bedtime to be taken in milk. 

In nervous headache the accompanying prescription 
will often produce a happy effect: — 

R. Acidi nitro-muriatici diluti, f.^ij. 

Strychnia, gr. \-%. 
Alcoholis, 

Chloroformi, aa f 3 i i j . 

Tinct. zingiberis, f 3iij. 

Aquae, q. s. ad f ^iii.— M. 
A teaspoon ful in water three times daily. 

In combination with quinia, chloroform may be given 
where there is marked tendency to frequent chills. The 
following formula would be very appropriate for such 



ETIIER. 191 

malarial manifestations in a child, say four 3'ears of 
age:— 

R. Quinae sulph. gr. xxiv. 

Mist, acaciae, f 5jij. 

Chloroformi, Tllxx. 

Syr. Tolu, £iv. 

Aquae cinnamomi, q. s. ad f 3 iij . 
3j s. t. d. for a child four years of age. — Da Costa. 

In certain forms of chorea and epilepsy the combina- 
tion of bromide of potassium and chloroform will be 
found valuable as follows : — 

R. Potassii bromidi, gr. x. 

Tinct. conii, TTLxxx. 

Chloroformi, TTLxx. 

Tinct. Valerianae ammoniatis, TH.x. 
Aquae camphorae, f ^j. 

For one dose ter die for an adult. 

In some cases advantage is obtained by adding st^eh- 
nia to this mixture in the dose of ^ to T \y, omitting the 
conium and the valerian. 

Ether. 

This is a colorless volatile liquid ; as it is also very 
inflammable, it must be kept carefully from the approach 
of fire or a light. It sinks in w r ater, and is best adminis- 
tered mixed with spermaceti and sugar, or in mucilage 
of gum arabic. Its taste is hot, pungent, and irritating ; 
and when placed in the mouth, ears, nose, or rectum, pain 
is produced. It dissolves in alcohol, whisky, or brandy ; 
and when required as a powerful stimulant, as in faint- 
ing, exhaustion, or collapse, this is an excellent method 
for administering it. In using it for some time it is best 
given enclosed in capsules. 

Gout. — In sudden attacks of gout in the stomach or 
intestines a useful mixture is the following : — 

R. Spiritus vini gallaci, 

^ther. aa f |j.— M. 

Dose, one teaspoonful in sugar and ice-water, repeated until 
relief is afforded. 

This same preparation will be found valuable in spasm 
of the stomach, or intestines, or heart. Ether has been 



192 ARTIFICIAL ANESTHESIA. 

proved useful in tape-worm, alone or combined with the 
oleo-resin of the male fern. The patient must live upon 
milk and a little bread for one day, and the following 
morning, fasting, take the full dose: — 

R. Oleo resinae felicis, gss. 
JEther. f J$j. 

Mucilag. acaciae, ad f Jss. — M 

This is to be repeated in three hours. In the evening 
food can be taken, to be followed with a full dose of cas- 
tor oil with twenty drops of spirits of turpentine. Some 
French authorities prefer to give f 3iss of ether alone, 
administered at once, and followed in two hours by the 
purgative. 

Ether is also one of our most potent remedies in hys- 
teria, especially when associated with valerian, assafce- 
tida, musk, or camphor. In the first with the fluid ex- 
tracts, as follows : — 

R. ^Ether. 

Valerian, ex. fluid, aa f 5J. — M. 
Sig. A teaspoonful every hour. 

In the second it is mixed with the tinctures as fol- 
lows : — 

R. Oilier. 

Tinct. assafcetidac, aa ^j. 
Mucilag. acaciae, ^j. — M. 
Sig A teaspoonful every hour until relieved. 

With musk: — 

R. Moschus, 9ij. 

Jitlier. 

Mucilag. acaciae, aa f Jj. — M. 
Sig. A teaspoonful every hour. 

With camphor ether is not only useful in hysteria, but 
all forms of " nervousness," in dysmenorrhea, diarrhoea, 
cholera, abnormal sexual excitement, epilepsy, hysteri- 
cal, puerperal, and strychnic convulsions. Camphor with 
ether is best administered as follows : — 

R. Vitelli ovi, ^ij. 

Pulv. camphorae, 3 ij. 
^Ether. fij.— M. 

Add the ether to the camphor, and then the emulsion. Ad- 
minister in tablespoonful doses every two hours. 



INHALATION OF ETHER IN ASTHMA. 193 

According to Zuelzer, ether can be used as a stimulant 
in small doses by hypodermic injections. He states that 
the symptoms of collapse are relieved by it, and abscesses 
are rare; the quantity recommended is one cubic centi- 
metre, or about sixteen minims. 

Asthma. — Inhalation of ether is verj' valuable to ob- 
tain relief in spasmodic asthma, and obtain sleep for the 
patient. It can be employed alone or associated with 
tinctura digitalis or conium. The ordinary dose of the 
ether is from ten to forty minims, and the tincture of 
digitalis from ten to thirty minims. 

The Ether Spray in Post-par turn Hemorrhage. — Mr. 
W. Handsel Griffiths, of Dublin, reports in the Prac- 
titioner the use of the ether-spray in two cases of post- 
partum hemorrhage, in which the usual means of arrest- 
ing the flow had been resorted to without effect. He 
directed the spray over the abdominal walls, along the 
spine, and over the genitals. In both cases the uterus 
contracted immediately, and hemorrhage ceased. 

Coryza and Obstinate Hoarseness. — Drs. Chapman and 
Physick recommended the vapor of equal parts of Hoff- 
man's anodyne or compound spirits of sulphuric ether 
with equal parts of laudanum in cases of recent catarrh, 
in coryza, and obstinate hoarseness, by inhalation.* 

Chorea. — A jet or hand spray of sulphuric ether, free 
from alcohol, applied to the spine will relieve the most 
violent spasmodic or convulsive attack of chorea, with 
the subsequent use of Fowler's solution, five to ten drops 
three times a day in water, and occasional application 
of the galvanic current to the spine. 

Nervous Aphonia, or Temporarg Loss of Voice. — The 
vapor of ether has been highly recommended as a most 
valuable remedy in hysterical or nervous loss of voice. 
It has been the means of discovering malingerers, who 
were supposed or stated to be deaf and dumb,f and who, 
as soon as they came under its anaesthetic influence, were 
able both to hear and speak. 

* I have also employed \ gr. of sulphate of morphia in the 
place of the laudanum, making- a more elegant preparation, and 
with good success. 

f See Turnbull's Manual of Diseases of the Ear, pp. 312-315. 
Phila., J. B. Lippincott & Co. 
It 



104 ARTIFICIAL ANAESTHESIA. 

Diphtheritic Angina, or Psendo- Membranous Croup. — 
Cases of diphtheritic angina have been treated with suc- 
cess by inhalations of ether and steam. 

Whoopiiig- Cough. — Ether alone by inhalation is ex- 
tremely useful in the relief of whooping-cough ; and a 
combination of ether sixty parts, chloroform thirty 
parts, and turpentine one part, has been found a most 
successful remedy, by confining the patient to his room, 
and making him, at every access of coughing, place before 
his mouth a small piece of cloth, folded several times, and 
wet with a teaspoonful of the mixture.* This remedy I 
have used with most gratifying results, at the same time 
employing, between the paroxysms, extract belladonna 
and quinine sulph. externally, with the inhalation of 
diluted carbolic acid in the patient's room. 

Chloral Hydras (C.CLO H-j-HO). 

I have, under Chloral Hydrate, given my views, experi- 
ments, etc. ; still there are one or two matters which I 
think it will lie well to state here. This agent has been 
found useful in all general convulsions and spasmodic 
diseases, which depend on direct disturbance of the 
central nervous system, but is contra-indicated in hys- 
terical convulsions, owing, as stated by " Binz,"y to the 
initial excitement which is so often present. It is best 
to avoid it also, or give it with great caution, in ulcera- 
tions of the primee vise, in gouty states, in typhoid 
fever (sec our experiments), and in disturbances of the 
circulation. (Liebreich.) Chloral hydrate should be 
given with great caution to patients with cardiac dis- 
ease. (Rosenstein.) 

Binz states the maximum of a single dose should be 
one drachm ; but it is safer to begin with ten grains, and 
repeated, which, under special circumstances, may be 
followed by 10 or 12 grains every hour. It is best given 
in an aqueous solution with gum and sugar; the ordi- 
nary syrup of chloral contains 10 grains to each drachm, 
the dose of which is 3 SS — 3U* 

* American Practitioner, July, 1875. 

f The Elements of Therapeutics, Translation, by Edward I. 
Sparks (1878), pp. 34-35. W. Wood & Co., New York. 



MEDICO-LEGAL RELATIONS. 195 

Dr. Bigelow, of Boston, reports in the Practitioner a 
case of tatanns, caused by a rusty nail, which was re- 
lieved by the introduction of a drachm of chloral into 
the wound, by a hypodermic syringe. 

Butylchloral (C 4 H 5 Ch 3 0), until quite recently, has been 
erroneous^ termed crotonchloral (C 4 H 3 Ch 3 0). (Binz.) 
This is a new narcotic. The method of preparing it is to 
act upon aldehyde with chlorine. It forms foliacious 
crystals, which are volatile when heated, and have a burn- 
ing taste. It is soluble with difficulty in cold water, more 
readily in warm, and dissolves quite readily in alcohol. 
It ought not to contain any chlorine which can be pre- 
cipitated by nitrate of silver. Its first effect is to pro- 
duce anaesthesia of the head, the rest of the body 
retaining its sensibility. This stage is followed by loss 
of function in the spinal cord, as evidenced by the gen- 
eral cessation of reflex irritability. The respiration and 
pulse remain unaffected. Still larger doses paralyze 
the medulla oblongata. But3 r lchloral, therefore, possesses 
the property of deeply narcotizing the brain without 
materially affecting the functions of the rest of the or- 
ganism. It is given in doses of three grains, repeated 
until fifteen grains have been taken. It is given in the 
form of pills, or else dissolved in syrup and water or 
glycerine. 



CHAPTER XL 



Medico-legal relations of anaesthetics. Case in Philadelphia of a sur- 
geon dentist. The important question whether chloroform can he 
administered for improper purposes. Cases in France, England, and 
the United States. Dr. N. L. Folsom, R. M. Denig. Ether as a poison. 
Experiments of A. Martin Ewald, Hitzig, C. Bernard and Binz. Chlo- 
roform ; its action as a poison, with the treatment. Ether intoxication. 

The responsibility attending the use of anaesthetics 
is of great importance to medical men, as frequently 
their personal and professional reputation is at stake ; 
it is therefore always better in the administration of an 
anaesthetic to a female to have some reliable person pre- 



196 ARTIFICIAL ANAESTHESIA. 

sent. This is especiall}' necessary when ether or chlo- 
roform is employed. 

During the early period of my medical career, soon 
after graduating, I had in my Quiz class a young ambi- 
tious dental surgeon, one of the most gentle and amiable 
of men, who was desirous of obtaining the medical de- 
gree, which he ultimately attained. Soon after this the 
man was married, and settled in this city, and acquired a 
large business. At that time it was common for the 
dentist to administer the anaesthetics in their office in 
the extracting of teeth, etc. He had a young female 
patient to whom he administered chloroform alone, and 
who afterwards stated that he had taken improper liber- 
ties with her person during this state. This case caused 
great excitement in our city, and the public sympathy 
was with the 3'oung female, and a suit was instituted in 
which damages were claimed. The case was argued by 
distinguished law\ r ers on both sides, and voluminous 
testimony taken. The judge charged the jury, and the 
sentence was ten years' imprisonment. Subsequently the 
sentiment of the community changed, and it believed 
that it was all the result of her vivid imagination, and 
that she was laboring under a delusion. The majority of 
physicians and dentists signed a petition, and the sen- 
tence was remitted, but his professional prospects were 
ruined. 

It is stated by Taylor,* " That the vapors of ether 
and chloroform have been criminally used in attempt at 
rape. In a case which occurred in France, a dentist 
was convicted of this crime upon a woman to whom he 
had administered the vapor of ether." Now this may 
be just such a case as the one in our own city. Ether, 
from its disagreeable taste and irritating vapor, would 
be much more difficult to administer forcibly and against 
the will of a patient. The numerous stories of anaesthe- 
sia by simply placing a few drops on a handkerchief 
under the patient's nose or mouth, are in the majority 
of cases perfectly absurd, as the shortest time required 
to bring a patient fully under the influence of either of 

* Taylor's Medical Jurisprudence, Eng. ed., London, 1865, p. 
1006. 



MEDICO-LEGAL RELATIONS. J 97 

these drugs, even when forcibly held in contact, is from 
two to ten minutes, and if subsequent rough handling 
takes place the patient is at once roused up to make re- 
sistance by struggling. We were once called to a woman 
who had been in the habit of employing chloroform by 
inhalation from a small bottle, to cause sleep ; she acci- 
dentally when in a drows}^ state let the open bottle drop 
on the pillow, and its contents saturated the covering, 
and she with her face in it ; but instead of making her 
sleep soundly, it produced most distressing nausea, and 
the family were awakened by her efforts at vomiting, 
and so her life was saved, she not being able to arouse 
sufficiently to get rid of the offending matter, and which 
would have lodged in her trachea, or the contents of the 
stomach might have been brought into the bronchial 
tubes by a deep inspiration, and thus have caused suffo- 
cation. 

The former casein Philadelphia settled the important 
point in the minds of medical men of this city that this 
incomplete unconsciousness does not coexist with com- 
plete motor and sensory anaesthesia, and therefore anaes- 
thetics are employed without any fear in all important 
operations. These observations are in part corrobo- 
rated by two learned authors in a recent and most ad- 
mirable work* on medical jurisprudence, in which they 
state : — 

" A question of some importance to the medical jurist 
naturally occurs here, namety, ''Whether chloroform can 
be administered for improper purposes V We know, 
however, that comparatively, the insensibility from chlo- 
roform (and more slowly from ether) vapor is onlj' slowly 
induced. It would be difficult, therefore, to administer 
chloroform forcibly and against the will, while, of 
course, the stories of immediate anaesthesia produced by 
it are but idle fables. Still, it might be administered to 
persons asleep without much difficulty (Lancet, Oct. 5, 
1872, p. 514, and Oct. 12, 1872, p. 549), and this seems 
the only possible condition under which it could be con- 

* Forensic Medicine and Toxicology. By W. Bathhurst Wood, 
M.D., F.R.C.P., and Charles Mayniott Tidy, M.B., F.C.S. Lind- 
say & Blakiston, 1877, p. 457. 

17* 



198 ARTIFICIAL ANAESTHESIA. 

veniently used for improper purposes, unless considerable 
force was employed to prevent the person struggling, 
which under ordinary circumstances would be an almost 
insurmountable difficult}' to its use." 

The following case (reported in the Philada. Medical 
Times, December 22, 187?), which quite lately occurred 
in England, more completely confirms our own observa- 
tions and experiments on this important subject: — 

"A case of the utmost importance to the whole pro- 
fession, not in Great Britain only, but everywhere, was 
tried before Mr. Justice Hawkins, at the assizes at North- 
ampton, on the 9th of November. It was a charge against 
a surgeon's assistant of criminal assault, — of rape upon 
a patient when under the influence of chloroform. If 
there is a dastardly crime, it is to take advantage of a 
woman's helpless unconsciousness to violate her person. 
And so the magistrate thought, who sent the accused to 
jail on the 14th of September, declining to hear any- 
thing in his favor, and resolutely refusing to accept bail. 
The charge was that a married woman named Child went 
to the surgery of her family medical attendant to have 
her teeth operated upon. She had been there a day or 
two before, but the attempt to put her under chloroform 
then failed. A second attempt was rather more success- 
ful. She evidently had some peculiarities or idiosyncra- 
sies in relation to chloroform, for he gave it for an hour 
and yet she was never sufficiently under its influence to 
admit of the operation being performed. She was accom- 
panied by a friend, — a Miss Fellows. At the end of the 
hour Miss Fellows went out of the room and saw Mr. 
Child. In a quarter of an hour Miss Fellows returned. 
The prosecutor maintained that on Miss Fellows's re- 
turn she was quite conscious, but unable to speak. Find- 
ing it impossible to perform the operation, the accused 
accompanied the prosecutrix and her friend home. So 
far Mrs. Child had been unable to speak, but shortly 
after the accused left the house she complained to her 
husband that he had taken advantage of the absence of 
Miss Fellows to assault her criminally. Next day, when 
the accused called, he was told about what she had said, 
and he replied that she was laboring under a delusion. 
Under cross-examination Mrs. Child said that she told 



MEDICO-LEGAL RELATIONS. 199 

the accused that if he would admit the offence and quit 
the town (Birmingham) she would forgive him. This 
the accused declined to do, denying that he had commit- 
ted any offence. He was then given in custod}^. The 
prosecutrix stated that the offence was perpetrated im- 
mediately after Miss Fellows left the room ; that the 
prisoner went upon his knees and then assaulted her. 
Miss Fellows stated that on her return she found Mrs. 
Child in precisely the same position in the chair which 
she occupied when she went out of the room. Such were 
the facts of the case. It was quite clear that there had 
been either an assault committed, or that the woman was 
under the influence of a very pronounced delusion. The 
whole of the accused's conduct was in favor of 'the latter 
hypothesis. But in such a matter, where no third per- 
son was present, the statement of one of the two parties 
concerned must be taken. When a woman whose char- 
acter was apparently without blemish (for in cross-exam- 
ination no attempt was made to call her reputation in 
question) makes a definite charge against a man of as- 
saulting her under circumstances which permitted of 
such an assault, the law could only send the case to a 
jury. In the mean time the unfortunate surgeon's assist- 
ant was sent to prison. 

When the case came to be tried, a large number of 
medical men of repute came forward voluntarily to aid the 
accused's defence, and did this quite gratuitously. The 
chief witness for the defence was Dr. B. W. Richardson, 
F.R.S., whose celebrity is world-wide. As is well known, 
Dr. Richardson has studied anaesthetics very carefully 
and for many years. He stated that there were four 
stages or degrees in which chloroform operated. The 
first stage was that in which consciousness was not lost; 
there was resistance and a desire for air. In the second, 
consciousness is lost, but the operation is impossible, 
the patient screaming, often without provocation. The 
third stage is that of complete unconsciousness, and 
where all rigidity is lost. This is the stage which per- 
mits of operation. In his opinion the patient was in the 
second stage ; the third never having been reached. He 
stated that in his own experience he had known persons 
in this second stage to have delusions as to what had 



200 . ARTIFICIAL ANiESTHESIA. 

taken place during that time. He related a number of 
cases, and stated that the fact of such delusions being 
induced by chloroform was one of the earliest objections 
raised to its adoption. He related one case where the 
patient, a female, was being operated upon by a dentist, 
and alleged that the dentist criminally assaulted her. 
And this she persisted in, though her father, her mother, 
Dr. Richardson, and the dentist's assistant were all pre- 
sent throughout the whole time. She persisted in her 
conviction long after the effects of the chloroform had 
passed away; and Dr. Richardson said she was probably 
of that belief still. This evidence of Dr. Richardson's 
was corroborated by the experience of Dr. Hawksby, of 
London, and by Dr. Saundby and Mr. J. F. West, of 
Birmingham. The judge asked the jury if it was neces- 
sary to sum up, and the}' replied it was unnecessary, — 
they were already agreed upon a verdict of acquittal. 
Mr. Justice Hawkins pointed out that such a verdict 
would not be the slightest imputation upon the absolute 
sinceritj- of the prosecutrix, who no doubt firmly believed 
every word of what she had said. He then congratulated 
the accused upon having had an opportunity of fully vin- 
dicating himself from the charge preferred, and said that 
the verdict of acquittal did not mean that there was in- 
sufficient evidence, but that the accused was entirely 
cleared of any imputation in respect to the charge pre- 
ferred against him. There could be no doubt the prose- 
cutrix labored under a delusion. The accused was then 
discharged from custody, having been in prison two 
months for no offence. It is not merely that this unfor- 
tunate man was imprisoned for two months for an ima- 
ginary offence, but that any man who is present when a 
woman is being put under chloroform is liable to have 
the same charge brought against him, that gives this 
case its gravity and importance. 

Such being the case, it becomes necessary that a 
little more should be known amidst the profession, as 
well as the lait}', as to the occurrence of erotic sensa- 
tions in woman. The subject is not a very pleasant one, 
but that is no reason why it should not be investigated. 
If it is a fact, and there is no doubt about this, that 
women when being put under chloroform are liable to 



MEDIOO-LEGAL RELATIONS. 201 

those erotic sensations which they experience from sex- 
ual intercourse, the sooner the fact is generally known 
the better. It is just the mystery which surrounds such 
facts that permits such a monstrous hardship as that 
mentioned above to be a possibility at all. Of course it 
is obvious enough to any one that it is a delicate matter 
to inquire into the subjective sensations of women. But 
if these subjective sensations tal^e the practical form of 
a charge of rape, two months in jail, and a trial by jury, 
they pass from the domain of sentiment and enter that 
of stern reality. Few, comparatively few, of the profes- 
sion seem to be aware that women are subject to condi- 
tions and sensations identical with those associated with 
the sexual act, which arise quite subjectively and without 
any extrinsic stimulus. The delusion of St. Catharine 
that the devil visited her every night and enjoyed her 
person when she was asleep and could offer no resistance, 
is no unique experience, but one common enough to 
woman. Every one familiar with asylum work knows 
that a certain percentage of women patients have the de- 
lusion, among others, that the medical superintendent 
comes nightly to their bed and violates their person dur- 
ing sleep. Of course there is no foundation of any kind 
for such a delusion, except the subjective sensations of 
the woman herself. How strongly such a delusion, how- 
ever, may be fixed in a woman's mind is evidenced by 
the case related by Dr. Richardson, where the woman 
persisted in her belief though her own father and mother 
as well as others were present, and where such assault 
was physically impossible. Such being the case, it be- 
hooves every man who is to be present with a woman 
when she is to be placed under chloroform to see that 
there is at least one other person present, and that, too, 
the whole time, without intermission, during which the 
woman is under the influence of chloroform, and that 
such other precautions be taken as will preclude the pos- 
sibility of such a charge being raised. That Mrs. Child 
charged this unlucky man in good faith need not be 
questioned for a moment. She was far from being hos- 
tile to him, for she offered if he would avow his guilt and 
leave the town she would forgive him. The charge was 
not pressed from any rancorous spite; that is abundantly 



202 ARTIFICIAL ANAESTHESIA. 

clear. But it is equally clear that something had occurred 
to that woman which she interpreted into the sexual act, 
and that this was so firmly fixed in her consciousness 
that it could not be dislodged. It becomes necessary 
then that the subjective sensations of woman should be 
investigated and made the subject of scientific observa- 
tions, and seeing that they exist they must have a scien- 
tific value; and that no prudishness should prevent 
attempts being made to ascertain what the actual facts 
are, and what is their interpretation." 

The following is the experience of Dr. N. L. Folsom, of 
Portsmouth, New Hampshire, in the same line : — 

" In 1854, a clergyman's sister came to ray office for 
the purpose of taking ether and having a tooth extracted, 
and brought her brother's wife with her. I began to ad- 
minister the ether fco the patient, and whilst renewing it 
she got away from me, and seemed alarmed and offended. 
I did not attempt to compel her to breathe any more 
ether, but urged her to take it, and so also did her 
brother's wife, but she would take no more. She had 
the impression, so her brother told me, that I attempted 
to violate her, and that his wife assisted me. It was a 
long time afterward before she would fully give up that 
she was mistaken in the matter."* 

AVe are almost certain after a number of careful expe- 
riments that chloroform and ether can be administered in 
sleep, so as to produce the first stage of anaesthesia, and 
can be carried to full completion or total unconsciousness. 
Still this is rare without disturbing the patient's stomach, 
causing nausea, or irritation of the lungs, with risk of 
sudden death, by its dense vapor, and thus rousing him 
or her to consciousness, or a condition in which the pa- 
tient can resist its influence, if the part}' is willing to 
make the effort. Another important point is that loud 
talking or handling, even in some cases the slightest 
touch or pain in any way, will cause the patient to start, 
and rouse him to resist. In the case of ether the patient 
can almost always see indistinctly, and in some instances 
is able to talk during the anaesthetic state. 

Dr. R. M. Denig,f of Columbus, Ohio, in an article on 

* Med. Surg. Reporter, January 12, 1877. 
f Ohio Medical Recorder, January, 1877. 



CHLOROFORM: ITS ACTION AS A POISON. 203 

the Medico-legal Relations of Chloroform, propounds the 
following queries: — 

" 1. Can they be administered successfully to persons 
during natural sleep without awakening them? 

2. Can the}' be forcibly administered for criminal 
purposes in opposition to the will of the person to whom 
they are given ? 

3. Can a person give competent testimony as to what 
occurred during the anaesthetic state?" 

His general conclusions are, that it cannot be used 
successfully for felonious purposes, and that a person in 
the anaesthetic state is not a competent witness. He 
gives the following example : — 

"Most of you are cognizant of a transaction which 
took place in our city a few years since, and which for a 
time produced the wildest consternation. Two employes 
in the service of an express company were said to have 
been chloroformed during sleep, the keys to the safe ab- 
stracted from their pockets, and the safes robbed of their 
valuable contents. A sponge, which bore the decaying 
fumes of chloroform, was found near the head of one of 
the messengers, etc. The whole thing was well gotten 
up, and was calculated to deceive even the most incredu- 
lous, and excite a sympathy in behalf of persons who had 
not only been robbed but nearly strangled. In less than 
a week, however, the possession of large sums of money 
led to the arrest of the supposed chloroformed indi- 
viduals, and to their incarceration in the Ohio State 
prison." 

Chloroform ; its Action as a Poison. 

Chloroform is not a very active poison. In a case 
quoted by Taylor,* an individual swallowed four ounces. 
He w r as able to walk a considerable distance after taking 
this large dose, but subsequently fell into a state of 
coma ; the pupils were dilated, the breathing was ster- 
torous, the skin cold, pulse imperceptible, and there were 
general convulsions. He recovered in five days. {Med. 
Gaz., vol. 47, p. 675.) A second case reported swallowed 

* On Poisons, Philadelphia, 1875, p. 618. 



204 ARTIFICIAL ANAESTHESIA. 

nearly two ounces, and recovered ; and a third swallowed 
two ounces, but he died in six hours afterwards. In this 
case the pupils were fully dilated, the breathing was 
stertorous, and the skin covered with a cold perspiration. 
On inspection, the lungs were found much engorged 
with blood, and there were some apoplectic effusions in 
these organs. The stomach was slightly inflamed in 
patches, and the mucous membrane was softened. (Am. 
Journ. Med. Sci., October, 1866, p. 571.) A physician, 
jet. 57, swallowed three ounces of chloroform. He im- 
mediately began to stagger, as if intoxicated. He 
vomited, and sunk into a deep stupor, and was in a state 
of complete amesthesia. His skin was pale and tolerably 
warm ; the muscles were relaxed, the breathing short, 
and the action of the heart weak and intermittent. In 
about fourteen hours sensibility returned. Acute gas- 
tritis ensued, with rapid collapse, and proved fatal in 
twenty-nine hours from the time the chloroform was 
taken. (Am. Journ. Med. Sci., Januaiy, 1870, p. 276.) 
Treatment. — In poisoning from liquid chloroform, the 
stomach pump and emetic should be resorted to. If evi- 
dence of suspension of the action of the heart (syncope) 
exists, there should be free exposure of the face to a cur- 
rent of air, compression of the chest, and artificial re- 
spiration, with warm applications, to the chest with 
active friction and stimuli externally and by the rec- 
tum. The poles of a galvanic battery applied to the 
chest and side of the neck with sponges dipped in hot 
water should be used. Spirit of ammonia has been 
found useful when injected l)3 r podermically, and strych- 
nia in the same way, to act upon the respiration. This 
must be given in minute doses, and great care must be 
given to the gastritis, and disturbance of the liver, which 
are apt to follow in the convalescence of the patient. 

Ethers ; in their Medico-Legal Relations. 

Ethers as a class are poisons, and, if taken into the 
stomach in very large quantities, will produce death. 
Still they can be employed for a long period without 
dangerous action on the heart and respiration. The 



ETHER INTOXICATION. 205 

habitual use of ether ruins the digestion, and causes 
chronic disturbance of the nervous system (see cases, 
subsequently reported), and this has been confirmed by 
A. Martin Ewald, of Berlin. 

In dogs, whose brains are exposed, the vigorous inha- 
lation of ether soon renders that organ completely insen- 
sible to the electrical current. (Hitzig.) 

After introducing ether into a dog's stomach, Claude 
Bernard observed an immediate secretion of a large 
quantity of pancreatic juice. There was vascular con- 
gestion of the intestine, and its secretions became more 
abundant, while absorption was accelerated. The chyle 
vessels were strongly injected, which must be explained 
by the abundance of pancreatic juice present in the 
bowel (Binz), the fine subdivision of the fat thus pro- 
duced, and the consequently increased facility with 
which it could be absorbed. 

If the blood be examined (Binz) after twenty drops 
of ether have been taken, the colorless corpuscles in it 
are found to be twice as numerous as usual. It is prob- 
able that here also ether has a direct action on the ab- 
dominal glands, and especially the spleen. 

Ether Intoxication. 

"A few years ago there was published in the Reporter* 
the ' confessions of an ether inhaler,' a member of our 
own profession, for whom it subsequently became our 
sad duty to sign a certificate of insanity. 

We are reminded of this by a paper in the London 
Medical Record, by Dr. Ewald, of Berlin, on a some- 
what similar case. It is that of a man aged thirty-two, 
who w r as lately admitted into the Charite Hospital, 
under Professor Frerichs, suffering from general debility 
and trembling of the muscles. On inquiry, it was found 
that he was notorious in Berlin for intoxicating himself 
with ether, his abuse of which had reduced him to his 
present miserable condition. He was originally temper- 
ate, and had been a university student, passing all his 
examinations with credit; he was, however, of a mysti- 

* Med. & Surg. Reporter. 



206 ARTIFICIAL ANAESTHESIA. 

cal turn of mind. Unfortunate^, a little more than 
nine years ago, there fell into his hands a medico-popu- 
lar treatise, in which the use and effects of ether, used 
medicinally, were described, and a glowing account 
was given of its effect in quickening the creative power 
of the mind. He procured about two or two and a half 
ounces of sulphuric ether, and inhaled it from a hand- 
kerchief; the result being to produce insensibility for 
about a quarter of an hour, during which time he im- 
agined that he lived for an indefinite time, and traveled 
over whole worlds. This condition, however, he was 
not again able to induce in so high a degree. Becoming 
gradually more and more addicted to his habit, he no 
longer confined himself to indulging himself in his own 
room, but, with his etherized handkerchief before his 
face, he wandered through the streets, purchasing small 
quantities of ether at the druggists' shops, until at last 
he became so great a nuisance to them that many of 
them closed their doors against him. He was also turned 
out of his lodgings, on account of the annoyance pro- 
duced by the smell of his breath, and became a house- 
less wanderer, reduced in means and in health. In the 
hospital there was no indication that his mind was 
affected ; his memory was not impaired ; his style of 
speaking was fluent. On one occasion an attempt was 
made to produce complete anaesthesia. For this purpose 
more than seven ounces were required ; the ether being 
given by an inhaler, and loss being prevented by closing 
in the apparatus with cotton-wool. No sooner, however, 
was the inhalation stopped, than the state ofinsensibility 
passed off. He was then allowed to take the ether in 
his own way, by inhaling it from a handkerchief. Given 
in this way, it produced a stage of excitement, during 
which he danced about the room, talked nonsense, and 
appeared much pleased, but there was no true narcotism. 
It was not thought justifiable to subject him to other 
experiments with ether, as it was desirable to break 
through his habit. It is interesting, that his suscepti- 
bility to the action of cannabis indicawas not impaired. 
This drug was given as a substitute for ether, and on 
the first occasion, too large a dose having been given, 



ETHER INTOXICATION. 20T 

the result was the production of phantasms, such as are 
induced by the smoking of hasheesh." 

The late Dr. Morgan, of Dublin, states that ether is 
employed in certain portions of Ireland as a substitute 
for whiskey. 

A case has come under the writer's notice in which a 
patient began the use of sulphuric ether in teaspoon ful 
doses, as a nervine ordered b}^ a physician, and ultimately 
increased the dose to one pint per day. When informed 
of its injurious character, she had lost her appetite, and 
suffered gastric disturbance ; she gradually diminished 
the quantity, and was able to give it up after a month 
or two. The only effect it had upon her was to give 
her apparent strength to go on with her teaching of 
music. Large quantities of ether have been taken in- 
ternally, and, so far as we have been able to learn, no 
death has yet occurred from its use in this way. 



208 APPENDIX. 

APPENDIX. 

THE DISCOVERY OF THE ART OF ARTIFICIAL ANAESTHESIA. 

In point of time, December 11, 1844, Wells, a dentist 
of Hartford, Connecticut, made the first successful appli- 
cation of nitrous oxide gas to relieve the pain of the 
extraction of a tooth, although the fact was known and 
published long before by Sir H. Davy, who proved in 
his own person that the inhalation of the gas would re- 
lieve intense pain in the teeth. Dr. Jackson, of Boston, 
afterwards suggested to Dr. Morton, a dentist, the appli- 
cation of sulphuric ether, which had also been known and 
employed for amusement in the medical lecture rooms. 
Dr. Morton, after numerous and careful trials on his 
own person and others, succeeded (September, 1846*) 
in proving this agent, if carried to a certain stage, a true 
anaesthetic to abolish sensation in long and painful ope- 
rations. Dr. Jackson, who gave a hint to the discoverer, 
was not entitled to the credit he received from the French 
and other governments, but only he, who by labor, great 
application, and perseverance, was successful at last in 
proving to the world that sulphuric ether was a true, 
potent, and pine anaesthetic, safe and applicable in al- 
most every instance. Dr. Morton was as much the 
inventor of modern anaesthesia as Jenner was of vaccina- 
tion, or Morse of the electro-magnetic telegraph. Mor- 
ton's great mistake was in procuring a patent. Dr. 
Long, of Georgia, has put forth a claim which has been 
stated very fully by Dr. Marion Sims, of New York. 
It is based on the personal evidence of friends and 
neighbors, but was never published to the world until 
December, 1849. 

In 1847, Prof. Simpson discovered chloroform to be a 
good substitute for sulphuric ether, by experimenting 
on himself and friends. His first public test was by ren- 
dering insensible a patient of Dr. Miller. 

* For a full account of this discovery see History of the Dis- 
covery of Modern Anaesthesia, by Prof. If. G. Bigelow, in "A 
Century of American Medicine:"' H. O.Lea: Published, 1876. 
Also, Discovery of Anaesthesia, by Dr. J. M. Sims, Virginia Med. 
Mod., May, 1877. History of Modern Anaesthetics, by Sir James 
Simpson, of Edinburgh : James Campbell & Co., Boston, Mass. 



1 N 1) K X 



A FTER-TREATMENT of anaes- 
A thetized patients, 20 
Alcohol as an anaesthetic, 17 

as a local anaesthetic, 182 
methylic, 18 
Amyl, nitrite of, 92 

to antidote ether and 
chloroform, 94 
Amylene, 75 

Anaesthesia, artificial, discovery of, 
208 
from rapid breathing, 171 
local, 172 

of the head (butylchlo- 
ral), 195 
Anaesthetic, chloral as an, 126 

mixtures, 18 
Anaesthetics, action of, on the blood, 
143 
in labor, 85 
list of, 16 

medico-legal aspect of, 195 
mode of action of, 152 
of the ancients, 13 
Asphyxia, 40 

from nitrous oxide gas, 137 



BICHLORIDE of methylene, 73 
deaths from, 74 
Blood, action of anaesthetics upon, 

143 
Brandy prior to the anaesthetic, 17 
Bromide of ethyl, 76 
Bromoform, 79 
Butylchloral, 195 



CiARBOLIC acid as a local am 
' thetic, 183 
Chloral hydrate, 112 

as an anaesthetic, 126 
hypodermically, 127 

19 



Chloral hydrate — 

internal use of, 194 
in tetanus, 123 
poisoning by, 194 
Chloroform, administration of, 83 
and morphia. 96 
antidote for, 92 
bibliography of, 155 
causes of fatality of, 105 
criminal use of, 197 
dangers of, 84 

in renal disease. 110 
deaths from, 67, 84, 97 
during labor, 86 
ether, and alcohol (mixture 

of), 18 
externally, use of, 185 
general conclusions concern- 
ing, 106 
in ovariotomy, 65 
internally, use of, 184 
mixed with the spirit of wine. 

66 
narcosis, method of resusci- 
tation (Nelaton), 87 
physiological action of, 92 
poisonous action of, 263 
preparations of, 187 
to antidote strychnia, 185 
treatment of poisoning by, 

204 
versus ether, 111 
versus nitrite of amyl, 94 
Croton chloral, 195 



ETHER, administration of, 21 
alleged dangers of use of, 61 
bibliography of, 155 
comparative merits of chloro- 
form and, 111 
danger from use of, 40 
deaths from use of. 41 



210 



INDEX 



Ether- 
experiments with, 32 
fainting, syncope, etc., from. 

41 
favorable conclusions con- 
cerning, 62 
in bronchitis, 44 
internally, use of, 191 
intoxication, 206 
medico-legal consideration 

of, 204 
mixed with chloroform, 65 
physiological action of, 22 
precautions in use of, 22 
preparations of, 192 
pulse writing, after inhala- 
tion of, 45 
sulphuric, 40 
syncope after use of, 51 

following use of, case, 47 
test for full anaesthesia from, 

22 
versus chloroform, 44 
vomiting prevented by bro- 
mide of potassium, 22 
warning symptoms of, 40 
Eucalyptus extract, for looal anaes- 
thesia, 182 



HYDROBROMIC ether, 76 
action on the pulse. 7s 
as an anaesthetic, 78 



ICE and salt, for local anaesthesia. 
183 
Inhaler, Allis' chloroform, 83 

ether, 27 
Angrove's ether, 36 
Carter's ether, 24 
Cheatham's ether, 25 
Clover's (ether and nitrous 

oxide gas), 161 
Codman <fe Shurtleff's (ether 

and nitrous oxide gas), 167 
Hawksley's ether, 24 
Lente's ether, 26 
Morgan's ether, 34 
Richardson's ether (B. W.,of 

Dublin). 35 



UANDRAGORA wine, 13 

iU Methylene, bichloride of, 73 

Methylic alcohol, 18 

administration of, 19 
ether, 72 
Mixed narcosis, 96 
Mixtures, chloroform and alcohol, 18 
and ether, IS 
(Atlee's), 65 
Morphia as a local anesthetic, 183 
Mortality statistics of ether, 41 

VITRITEofamyl, 92 

-Li to antidote chloroform or 

ether, 94 
Nitrous oxide gas, 129 

and ether, 161 
bibliography of, 155 
constriction of the glottis, 

137 
deaths from, 156 
liquefied, 134 
manufacture of, 130 
physiological action of, 

139 
post-mortem appearances 

following death from, 

159 



OVARIOTOMY, bichloride of me- 
thylene in, 75 
chloroform and ether in, 65 
Oxide of ethyl, 21 



OCAL 



■thesia, 172 



RENAL disease, dangerous to ad- 
minister chloroform, 1 111 
Rhitrolene., 173 



STATISTICS of mortality from 
O chloroform, 109 

from ether, 41 
Strychnia, to antidote chloral, 127 
Symptoms, warning, from ether, 51 
Syncope from ether, 47 

from nitrous oxide, 137 
from chloroform, 101 



TABLE of anesthetics (Richard- 
son), 41 
Tetanus, chloral hydrate hypoder- 
mically for. 195 



THE END. 



Bv the same Author 



A CLINICAL MANUAL 



DISEASES OF THE EAR. 



INCLUDING THE 



Anatomy, Physiology, Pathology, and Treatment, 



By LAURENCE TURNBULL, M.D., 

Aural Surgeon Jefferson Medical College Hospital; Physician to the Department of 
the Eye and Ear, Howard Hospital, Philadelphia. 



8vo. 500 pages. 106 Illustrations. Full Index, etc. Price 



TESTIMONIALS. 
From D. Hayes Agnew, Professor of Surgery, Univ. of Pennsylvania. 
Your work on Diseases of the Ear will, in my judgment, not 
suffer in comparison with any book published on this subject. 



From Dr. John F. Meigs, the able Author of the best work on Diseases of 
Children in the English language. 

Now that I have looked over your work with some care, I am 
ready, not only to thank you, but to thank you very much, for so 
good an account of the present knowledge possessed by our pro- 
fession in regard to these diseases, and also for your own contribu- 
tions in the treatment of these troublesome affections. 



From Professor S. D. Gross, the Nestor of American Surgery. 
I think your book will add another laurel to the triumphs of 
American medical literature. 



From Dr. H. Knapp, of New York, a distinguished teacher and authority 
in Ophthalmology and Otology in the United States. 

Dr. Turnbull's work is an exhaustive compilation of everything 
that is practically worth knowing on the subject ; while, at the 
same time, the author's own experience and judgment, everywhere 
deliberately expressed, serves as a guide in matters which are still 
sub j a dice. 

From the "American Journal of the Medical Sciences." 
The plan of the work is comprehensive, and, besides the anatomy 
and pathology of the ear found in all aural text-books, includes 
chapters on the ''Physiology of Hearing," "Acoustics," and 
"Deaf-Mutism." The last gives an interesting account of the 
different systems of teaching deaf-mutes, and the principal institu- 
tions devoted to that object The book gives evidence 

of research ; ite bibliography is copious, and it presents a full sum- 
mary of the subject of which it treats Indeed, it might 

almost be called an aural encyclopaedia. 



From the "Leavenworth Medical Herald." 
This book is unquestionably a work of the highest excellence, 
rich in information, and, perhaps, fuller in details than any text- 
book on the subject with which we are acquainted. The author 
has treated the subject of the ear with judgment and ability. 



From the " Monatsschrift fur Ohrenheilkunde, Berlin." 
After perusal, the purpose of the author is to impart to his coun- 
trymen, who have not paid much attention to "Otology," the 
results of the studies of other specialists, and he has furnished them 
an ample exposition of the present state of this branch of medicine. 
From this point of view. TurnbulPs handbook deserves our praise. 
Our author gives ample quotations from the works of others, but 
does not, however, withhold his own judgment and experience, 
which is interesting. Dr. Turnbull proves himself thoroughly ac- 
quainted with the literature of the subject, and employs it very 
properly. 



From the " Boston Medical and Surgical Journal.' 
Sound, clear, and eminently practical in all its parts. 



From the " Dublin Journal of Medical Science." 
It is worthy of note that the two hest works on Otology of the 
present day — viz., Turnbull's and Roosa's — both emanate from 
the American press. 



From the " Detroit Review of Medicine." 
A book of great value to all, both specialist and general prac- 
titioner. 



From the " Atlanta Medical and Surgical Journal." 
Dr. Turnbull's book will be of great service to all who purpose 
to keep pace with the progress in this department of our profes- 
sion. Every physician should have it. 

From the " Transactions of the American Otological Society." 
In connection with the tables of classification, a schedule of the 
method of investigation in various diseases of the ear is given, 
which is of decided practical value to the student. . . . There 
is, in addition, a bibliographical table, including 440 works relat- 
ing to Otology, and a full index. 



From the " St. Louis Medical and Surgical Journal." 
On the whole, the work is a valuable one, and such as we can 
recommend. 



From the "Cincinnati Lancet and Observer." 
Take it altogether, we think our readers cannot do better than 
to place a copy of" Turnbull's Manual of the Diseases of the Ear" 
in their library for reference. 



From the "Canada Lancet." 
The work deserves well of the profession, and will, no doubt, 
sooner or later, find a place in every reading man's library. 

From the "Philadelphia Medical and Surgical Reporter." 
The book, as a whole, is the very best work on aural complaints, 
for the general practitioner, with which we are acquainted. 



JPSP For sale by Booksellers generally, or will be sent by mail, 
postage paid, on receipt of the price. 

J. B. LIPPINCOTT & CO., Publishers, 

PHILADELPHIA. 



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